CHICAGO RADIOLOGICAL SOCIETY

A DIVISION OF ILLINOIS RADIOLOGICAL SOCIETY

475 S. Frontage Road, Suite 101 • Burr Ridge, Illinois 60527-6282

Ph: 630-323-5344 • Fax: 630-323-6989

Email: [email protected] • Web Site: www.chi-rad-soc.org

 

CHICAGO RADIOLOGICAL SOCIETY

2005-2006 Season Dinner Ticket Order Form

Name: _________________________________________________________________________

Institution:_____________________________________________________________________

Address:_______________________________________________________________________

_______________________________________________________________________________                                                                                                                                            

Telephone:_____________________________________________________________________

Number of season tickets requested:_______________________________________

                                                                       (@ $200 per season ticket)

                                                Total Remitted: $_____________

Please send completed season ticket form and remittance payable to “Chicago Radiological Society” to:

Carl L. Kalbhen, M.D.
Radiology Department

Northwest Community Hospital
800 W. Central Road
Arlington Heights, IL 60005

Reservation and meal choice need to be faxed (847/618-5958), phoned (847/618-5916) or emailed ([email protected]) to Marcy Gustafson by the Wednesday of the week before each meeting date.

Season tickets will also be available for purchase at the October 20, 2005 meeting.