West Virginia Society of Radiologic Technologists

Application for Membership

I hereby make application for membership in the West Virginia Society of Radiologic Technologists.

Name: (LAST) _____________________________(FIRST)_____________________(MI)_________

Address: ___________________________________________________________________________

City: ______________________________________ State: ___________ Zip: ___________________

Credentials: (Check all that apply):

RT(R) ___ (M) ___ (CT) ___ (CVIT) ___ BSRT ___ BART ___ ASRT _____ Other________

ARRT # __________________________ WV State License # ________________________________

Home Phone: ______________________ Work phone: _____________________________________

Email address: ______________________________________________________________________

Applying for: First time membership _____ Renewal _____ .

Membership year runs annually from the date of application

_____ ACTIVE MEMBERSHIP: member of the ASRT (include a copy of your current membership card). Voting member

_____ ASSOCIATE MEMBERSHIP: not a member of the ASRT. Applying for WVSRT membership only. Non-voting

_____ SUPPORTING MEMBERSHIP: commercial representatives, Physicians, inactive radiography employment status.

_____ STUDENT MEMBERSHIP: Name of program: _____________________________________________________

Membership Fees: (Circle the appropriate fee)

Signature: ____________________________________________________Date: _________________

Make all checks payable to: “The West Virginia Society of Radiologic Technologists”

Return form and payment to: Lisa Knight RT (R) Rt. 4 Box 254C Clarksburg, WV 26301