ARKANSAS SOCIETY OF RADIOLOGIC TECHNOLOGISTS

Membership Application

I hereby make application for membership in the Arkansas Society of Radiologic Technologists for year 20___,

And if accepted I agree to support the by-laws of the ArSRT and promote the aims of the organization.

Please type or print clearly

NAME:

____________________________________________________________________

Last First Middle Maiden

ADDRESS:

____________________________________________________________________

Street/PO Box City State Zip

E-MAIL ADDRESS______________________________________(Must have to receive ArSRT newsletters)

EMPLOYER_____________________________________

PHONE: HOME: ( )______________ WORK: ( ) ________________

( ) NEW MEMBER

( ) RENEWAL OF MEMBERSHIP : MEMBERSHIP NUMBER_________(ON ArSRT CARD)

CATEGORY OF MEMBERSHIP (SELECT ONLY ONE)

( ) ACTIVE ( ) ASSCOCIATE ( ) LIFE

( ) STUDENT School Attending___________________________ First Year_____ Second Year_____

DO YOU BELONG TO THE AMERICAN SOCIETY OF RADIOLOGIC TECHNOLOGISTS? _______

Ken Baltz Memorial Fund:

( ) I wish to contribute to the memorial fund:

Amount of Contribution: ___________ Please make separate check payable to: Ken Baltz Memorial Fund

CURRENT FEES: PLEASE MAKE CHECKS PAYABLE TO: ArSRT

( ) $50.00 ACTIVE (Registered by the ARRT)

( ) $85.00 ACTIVE 2 Year Membership

( ) $50.00 ASSOCIATE (Licensed by the State of Arkansas)

(__) $85.00 ASSOCIATE 2 Year Membership

( ) $25. 00 STUDENT (Enrolled full time in an accredited program & not registered in any other discipline)

( ) LIFE (granted by the Executive Board, no dues required)

MAIL APPLICATION AND CHECK TO: ArSRT , PO BOX 241492, LITTLE ROCK, AR 72223

MEMBERSHIPS ARE NON-REFUNDABLE AND RENEWABLE EVERY JANUARY.

Deadline is February 28^th to be an active voting member.