ARC Registration Form

Advanced Radiotheraphy Consulting, Inc. (ARC)

100 E. Wayne Street, Suite 140
South Bend, IN 46601
Phone (574)232-2305 * Fax (574) 232-2200

Course Registration Form

Which course would you like to register for?

Courses*

Please enter the course date that you would like to attend.

Which course date would you like to attend?

Which date will you be taking the exam?

Virt-RON Courses

Course 1 Course 2 Course 3

Attendee Name*

Job Title*

Home Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Home Phone*

Cellphone*

Employed By*

Employed At*

Work Address*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Work Phone*

Fax

Email Address*

Please check if you are a Vegitarian

Yes

Caterer will be notified.

How would you like to pay?

Have you been to another ARC Review or Class?

Yes

Payment Method

Money Order Check: Make Checks Payable to ARC Visa / MasterCard / Discover / Amex

Credit Card*

Credit Card Expiration Date*

Credit Card Security Code*

Amount to be charged:*

Your Name*

First Name

Last Name

Date

How did you hear about us?*

FAX Email Flyer Mailer Website Referral

Other:

Disclaimer: ARC does not guarantee that the individual attendee taking the applicable certification will pass the exam.

Terms of Service

To submit this form you must agree to the Terms & Conditions outlined here.

Today's Date

I agree to the outlined Terms & Conditions*

Confirmation Page

Thank you for filling out our form. You will be redirected to our website. Please give us 24hrs to process your application. If we receive an application on the weekend you may have to wait until the next business day.

Respectfully yours,

John