APPLICATION FOR MEMBERSHIP

Last Name: ____________________________ First Name: ________________________   M.I.: _____

Address: _____________________________ City: ___________________ State: _____ Zip: ________

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

PO BX 25568

Greenville SC  29616