* Last/Family Name:

* First/Given Name:

* Title:
-- select one -- Dr. Ms. Miss Mrs. Mr.

Middle name:

* Complete Home Address:

* Home phone number:

* Alternate phone number:

Dietary restrictions:
Vegetarian Vegan None Other

If "Other," please specify:

Do you have a valid US driver's license? (international travelers only)
     Yes   No

Hotel Room Preference:
Smoking    Non-smoking

* Facility Name:

* Your position:
-- select one -- 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?    -- select one -- 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:

* Alternate Phone:

Physics/Application Courses:

Which class do you want to attend?
--select a class-- Medical Physics Program - Madison, WI USA (1 Week) Medical Physics Program - Antwerp, Belgium (1 Week) Applications Operator Station Program – Radiation Therapists (3 days) Applications Planning Station Program – Dosimetrists (3 days)

Course dates - first choice

Course dates - second choice

Technical Courses:

Which class do you want to attend?
--select a class-- Customer Technical Training (2 Weeks) Partner Technical Training (5 Weeks) Distributor Technical Training (9 Weeks)

Indicate preferred dates:

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.

Will you bring your personal radiation badge?     Yes   No

Do you need a translator?
Yes   No

If so, what language?