* Last/Family Name:

* First/Given Name:

* Work phone number:

Please enter a valid telephone number.

* Alternate phone number:
Please enter a valid telephone number.

Dietary restrictions:
Vegetarian Vegan None Other

If "Other," please specify:

* Facility Name:

* Your position:
Physicist Chief Physicist Radiation Oncologist Dosimetrist Radiation Therapist Other

* Complete Facility Address:

* Your e-mail:

How long have you worked with the Hi·Art^® system?    less than 1 year 1 – 2 years 3 – 4 years more than 5 years

TomoTherapy Inc. Sales Representative:

TomoTherapy Inc. Project Manager:

* Emergency Contact (full name):

* Relationship to you:

* Primary Phone:

Please enter a valid telephone number.

* Alternate Phone:

Please enter a valid telephone number.

Applications Planning Station Program – Dosimetrists (3 days)

Course dates - first choice
Oct 19 - 21, 2010 Nov 9 - 11, 2010 Dec 7 - 9, 2010

Course dates - second choice
Oct 19 - 21, 2010 Nov 9 - 11, 2010 Dec 7 - 9, 2010

Please note that course dates are not guaranteed. Our Learning Solutions Coordinator will follow up with you to determine dates available or place you on a waiting list.

How well do you speak/understand English?
Fluently    Fairly well    Adequately    With some difficulty