Kansas Society of Radiologic Technologists Membership Application

Kansas Society of Radiologic Technologists Application
Type Of Application
Name

First NameMiddle NameLast NameCredentials
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Format: (000) 000-0000.
Date of Birth (xx/xx/xxxx)
Membership Type
Present Employment or School
Date of Enrollment (Students Only)
Anticipated Graduation Date (Students Only)
Date of Application

MonthDayYear
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Membership Type
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Active Membership$50.00

Associate A or B Membership$50.00

Life MemberFree

Senior$25.00

Student$25.00
By submitting this form, you are agreeing to abide by the Bylaws of the Kansas Society of Radiologic Technologists. You are also aknowledging the information submitted is correct and accurate. You are also agreeing to pay the membership dues.
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Kansas Society of Radiologic Technologists Application