South Dakota Society of Radiologic Technologists

2008

Membership Application

(Please complete entire form accurately for proper membership processing)

Name: _________________________________________________

Maiden Name: (if within 1 yr)____________________________________

E-mail Address: ____________________________________________

Home Address: _____________________________________________

City/State/Zip: ____________________________________________

Home Phone: ___________________________

Employer: ___________________________________________________

Work Phone: ___________________________

____ ARRT & ASRT - $30	ASRT # ___________	ASRT Exp Date _____________
____ ARRT Only - $35	____ Non-RT - $35	____ Student - $15 1^st yr 2^nd yr (circle one)
____ Other Professional Affiliation/Society - $35 (send proof/copy of membership)

Are you a new member? Yes No

Would you like a SDSRT Certificate to be mailed to you? Yes No

Information must be complete and correct dues sent or application will be returned by mail

Send application form and payment to: Susan Speckels

(Make checks payable to: SDSRT) 300 S. Byron Blvd

Chamberlain, SD 57325