Nebraska Society of Radiologic Technologists
An affiliate of the American Society of Radiologic Technologists


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The Nebraska Society of Radiologic Technologists
An Affiliate of the American Society of Radiologic Technologists
MEMBERSHIP APPLICATION USING PAYPAL
MEMBERSHIP YEAR ENDING:  JUNE 30, 2013
NAME:  
  (First Name) (MI) (Last Name) (Maiden Name - If applicable)

S.S.N. #   Nebr. Licensure/Certification #:  

ADDRESS:  
  Street, PO Box, Apt # (City) (Select State) (Zip Code)

EMAIL ADDRESS:  

PHONE # (Home):   (Work)  
FACILITY & ADDRESS WHERE EMPLOYED:  

CHECK ALL THAT APPLY TO YOU

ARRT Registry #:  
Other  
Member of the ASRT? Expiration Date:  


Full Time Radiation Science Student (Documentation of enrollment from registrar must accompany application)
Educational Facility:  
Program being attended:  
Expected date of graduation:  

Commercial Representative - Company:  


MEMBERSHIP STATUS
 
All Membership Fees include a $2.00 PayPal Fee.