Alaska Society of Radiologic Technologists

Alaska Society of Radiologic Technologists

Application for Membership
ASRT Member? *

Yes No
Membership Fee is $25 if application is submitted by January 31st

Membership Fee submitted after January 31st will by $40

Student Membership Fee is $10 if submitted by January 31st

Student Membership Fee is $15 if submitted by after January 31st

Membership fee for 5 years is $100 submitted any time.

Membership fee any time after January 31st, including registration for/at the annual conference will be $40; $15 for Student.
Date *

- Month - Day Year
Date
Degree(s), Title(s) Imaging Specialties *
(BA, BS, MA RT(R)(?) Please indicate as desired to appear on membership card, name tags, etc.
Name *

First Name Last Name

Address *

Phone Number *

- Area Code Phone Number
Alternate Phone Number *

- Area Code Phone Number
Employer *
Current Employer
E-mail *
Preferred for sharing membership information & AKSRT educational opportunities
Preferred AKSRT contact method for updates and activities *

Email 1 Mailing Address 2 Both 3
Type of Membership *

New Member (Never applied before) 1 Continuing member (Renewing membership) 2
My Products *

Membership Fee before 1/31 $ 25.00

Student Membership before after 1/31 $ 10.00

5 Year Membership $ 100.00

Total $ 0.00
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