Membership
Application
Please
print this application and submit it by mailing to the address below along with
your check.
Please fill out completely. Please
print or type.
Name: __________________________________________________________________________________
First
Middle Initial
Last
Professional Initials
(BS, RT)
Address:
__________________________________________________________________________________
Street and Number
City
State
Zip
Telephone:
( )
(
)
Home
Business
E-Mail:
_____________________________________________________________________
| Position Type: | Discipline/Specialty: | Committee you wish to serve on: | |
| ( ) Staff Technologist | ( ) Radiography | ( ) By-Laws | ( ) CSRT Publications |
| ( ) Student Position | ( ) CT | ( ) Annual Conference | |
| ( ) Supervisor/Manager | ( ) Radiation Therapy | ( ) Educators | |
| ( ) Educator | ( ) Ultrasound | ( ) ECE | |
| ( ) Commercial | ( ) Mammography | ( ) Meeting Planning | |
| ( ) Inactive | ( ) MRI | ( ) Legislative | |
| ( ) CV | ( ) Nominations | ||
| ( ) Nuclear Medicine | ( ) Membership | ||
Please Check:
( ) New
( ) Renewal ( )
Active $25.00 ( )
Supporting $25.00
( )
Student $10.00
( ) Honorary
( )
Life [No Fee]
[No
Fee]
School Name _______________________
Graduation Date
_______________________
Referred By:
_____________________________________
Amount Enclosed: $___________
Dues
are for fiscal year Oct 1, 2007 through Sept 30, 2008
Make check payable to “CSRT”
and mail to:
Michael Kelly
2 Livingston Street Apt A32
New Haven, CT 06511