Membership App. and Renewal Form

ALABAMA SOCIETY
OF
RADIOLOGIC TECHNOLOGISTS

MEMBERSHIP APPLICATION
and RENEWAL FORM

Please complete this form for new membership or for renewal of membership. If this is a renewal, please update your personal information to assist us in keeping our records current. Once completed, click the 'Print' button below and follow the instructions. Please mail this form with your dues payment.

Last Name :		First Name :
Address :
City :		State :	Zip Code :
Home Phone :		SS # :
Work Phone :		Email Address. :
Employer :
Employer Address :
ARRT Certified?	Yes No	Area/s? R T N M CT
Registry. Number :		MRI CIT QM
What month do you renew your registry :
ASRT Member :	Yes No (if yes, please include a copy of your ASRT membership card)

Student Members :	A. Name of School :
	B. Date of Graduation :

Each year, the newly elected President chooses committee chairs and committee members from a list of ALSRT members who have stated that they are interested in working on a committee. If you would like for your name to be placed on the list, please check the YES box. Are you interested in working on an ALSRT committee? YES NO

MEMBERSHIP DUES
Active, Associate, Inactive, and Supportive			$30.00 Annually
Student Members			$10.00 Annually
Chapter : Radiation Therapist Educator			$10.00 Annually
Total Payment Enclosed:				$
Note: If joining a Chapter, total dues will be $40.00. Please indicate chapter above.

*ALSRT awards a scholarship annually based on availability of funds. You may contribute to this fund by adding a dollar amount to your membership dues.* $25 $50 $100 $300 Other (please specify)
Please print this form and mail it, along with your membership fee to: ALSRT P.O. Box 473 Northport, AL 35476 If you are a member of the following organizations, please provide a copy of your membership card: ARRT, ASRT, ALSRT

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