Associate Membership Application

October 1, 2012 – September 30, 2013
Associate Membership Yearly Dues are $35

 

 

Please fill out all the information below
Membership Renewal
New Membership Application
Last Name:
First Name:
Middle Initial:
Credentials:
Place of Employment:
E-Mail Address:
Preferred Mailing Address:
Is this Employment Address?
Home Address?
Address:
City:
State:
Zip:
Please Check Where Appropriate
Credentials:
AART
 Radiography
Nuclear Medicine
Radiation Therapy
Dosimetry
Mammography
Sonography
MRI
CT
CVT
QM
ARDMS
 RDMS
RDCS
RVT
CNMT
CMD
Other:
Educational Level, Degree :
Certificate
Applied Science
Associate Science
Baccalaureate
Masters
Doctorate
Other:
Position, Title
Dean
Associate/Assitant Dean
Department Chair
Program Director
Academic Faculty
Clinical Faculty
Other:
Rank
Professor
Associate Professor
Assistant Professor
Instructor/Specialist
Other:
Employment
Four-Year College/University
Junior/Community College
Vocational/Technical College
Academic Health Center/Medical School
Hospital/Medical Center
Department of Defense
Department of Veterans Affairs
Other:
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I support and will uphold ACERT's Constitution and Bylaws