NYSSRS New York Society of Radiological Sciences Inc. - Radiological Sciences, Radiology, Radioligist

NEW YORK STATE SOCIETY OF RADIOLOGIC SCIENCES, INC.

Application For Membership

NEW YORK STATE SOCIETY OF RADIOLOGIC SCIENCES, INC.

Please fill and submit this application online for our database with or without any payments.
For the student section where a signature is required, also print out the completed form and mail it in to the address provided.
Payments can be submitted online using PayPal at the bottom of this form, or mailing a check or money order.

All fields marked with a * are required:

MEMBERSHIP*

LAST NAME*

FIRST NAME*

STREET ADDRESS*

CITY*

STATE*

ZIP CODE*

HOME PHONE*

WORK PHONE

EMAIL ADDRESS

LAST FOUR DIGITS OF SS#*

LOCAL SOCIETY MEMBER?

ARST MEMBER?

ARST NUMBER

CERTIFICATION ARRT REGISTRY NUMBER

Check All That Apply:

RADIOGRAPHY RT R

THERAPY RT

NUCLEAR MEDICINE RT N

SONOGRAPHY RDMS

SONOGRAPHY RT S

MAMMOGRAPHY RT M

CT RT CT

MRI RT MRI

CVI RT CVI

OTHER

LICENSES

Student Information

NAME OF PROGRAM

DIRECTOR

PROGRAM PHONE NUMBER

ANTICIPATED GRADUATION DATE

Applying For membership.

EMERITUS EXEMPT
(See Membership section for eligibility)

SCHOLARSHIP FUND DONATION
(Donations provided fund student activities)

Membership Fee  $ .00

Scholarship Donation  $ .00

Total  $ .00

MEMBERSHIP PERIOD IS FROM MAY 1ST THROUGH APRIL 30th.

RENEWALS NOT RECEIVED BY JUNE 1ST
WILL BE DELETED FROM MEMBERSHIP ROLL. (REVISED 01/05)