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License Request Form

Journal Requested: Combination Radiology & RadioGraphics Online (best rate)
  Radiology
  RadioGraphics
  Legacy Collection
Contact Name:
Licensee Address:
 
Phone:
Fax:
E-Mail:
   
License Type: Academic
  Hospital
  Corporate
   
RSNA Academic License:
       
Name 1: Highest Degree 1:
Name 2: Highest Degree 2:
Name 3: Highest Degree 3:
Name 4: Highest Degree 4:
       
Website 1:    
Website 2:    
Website 3:    
Website 4:    
RSNA Hopital License:
     
Site 1: Site Beds 1:
Site 2: Site Beds 2:
Site 3: Site Beds 3:
Site 4: Site Beds 4:
       
Website 1:    
Website 2:    
Website 3:    
Website 4:    
RSNA Corporate License:
   
Full Time Employees:
Relevant Full Time Employees:
Mission Statement:
Website: