APPLICATION FOR MEMBERSHIP
Last Name:
____________________________ First Name: ________________________ M.I.: _____
Address:
SS#: ____________________ School & Date of Graduation (If
Student)_____________________
Birthdate: ________________ Home Phone ____________________ Work
Phone: _____________
Employer:
___________________________________________
Department: ___________________
ARRT Number:
_________________ Other Modalities Credentialed in: ________________________
Are you a member of the American Society of
Radiologic Technologist? Yes _____ No _____
E-mail Address:_____________________________________________________________________
Status: (Please check one)
___ ACTIVE Shall be those individuals certified by the American
Registry of Radiologic Technologists as R.T.
(R, T, or N), those individuals with specialty
certification by the American Registry of Diagnostic Medical Sonographers, and
those individuals with specialty certification by the Nuclear Medicine
Certification Board. These individuals will be actively engaged in
the health care field, i.e. direct patient care, education, or administration,
and must show current membership in the American Society of Radiologic
Technologists. Active members shall hold
all rights, privileges and obligations of membership including the right to
vote and to hold office.
____
ASSOCIATE Shall be those individuals who meet all the
requirements of an Active member, except current American Society of Radiologic
Technologists membership. This will
include holders of the South Carolina Radiation Quality Standards
certifications. Associate members shall
have all the privileges and obligations of membership except the right to hold
office.
____ INACTIVE Shall be those persons who are no longer actively
engage in the field of radiation and imaging
specialties and who have applied for inactive status. They shall have the privileges and
obligations of active membership except the right to hold office.
____ STUDENT Students enrolled in accredited educational programs in
radiography, radiation therapy, diagnostic medical sonography,
or nuclear medicine technology. Student
members shall have all the privileges and obligations to active membership,
except the right to vote and hold office.
At the date of graduation, membership will expire with the members eligible
to renew membership as either an Active or Associate member.
___
SUPPORTING Shall
be those persons who are interested in promoting the purposes and functions of
this
Society, but who are not eligible for active,
associate, student, or inactive membership.
Fee Schedule ( Please
circle)
(RATES INCLUDE $ 5.00 APPLICATION FEE)
Active $
35.00 ( One Year) $
55.00 (Two Years)
Associate $ 35.00 ( One
Year) $
55.00 (Two Years)
Inactive $
35.00 ( One Year) $
55.00 (Two Years)
Supporting $
35.00 (One Year) $55.00 (Two Years)
Student $
25.00 (2 Year Membership expires at Graduation-not to exceed 24 months)
$
12.50 (1 Year Membership expires at Graduation or at the end of 12 months-not
to exceed 12 months)
Date: _____________________________ Signature:
________________________________________
Sponsoring Member:
___________________________
$40.00 returned check fee for insufficient funds
ENCLOSE COPIES OF
ASRT, ARRT OR SCRQSA CARDS AND RETURN
WITH THIS APPLICATION AND APPROPRIATE FEES TO:
SCSRT