First & Middle Name:

Last Name:

Email Address

Gender:

 Male   Female

Home Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Fax:

County:

Section:

Please notify the EXECUTIVE SECRETARY in writing
of any changes in status or address.

PLEASE ANSWER THE FOLLOWING QUESTIONS:
Must include copy of ARRT card or GMO state license

Credentials
(Check one
or more)

 Radiography (A.R.R.T.)
 Nuclear Medicine
 Radiation Therapy
 Diagnostic Medical Sonography
 M.R.I.
 C.T.
 Mammography
 Cardiovascular Interventional Technology
 Quality Management
 General Machine Operator
 Degree  

Position

Staff Management Education Sales Unemployed seeking job in field Unemployed not seeking job in field Employed in unrelated field Retired Other  

Work in:

Hospital Clinic/Urgent Care/Mobile Private Office College or University Commercial Company Other  

 Yes    No

Are you a member of ASRT?

 Yes    No

Interested in running for an OSRT board position?

 Yes    No

Interested in serving on an OSRT Committee?

DUES: $35/Year. Multiple year memberships available at reduced rates: Two-year: $65; Three-year: $90.

Birth month/year
(MUST Type-in)

ACTIVE MEMBERSHIP: Offered to those who hold registration with a recognized credentialing organization in medical imaging technology.

select one:

1 year membership 2 year member add $30 3 year member add $55  

Total Fees:

ASSOCIATE MEMBERSHIP: Offered to General Machine Operators and those who show an interest and support in promoting the purposes and functions of the Ohio Society of Radiologic Technologists.

select one:

1 year membership 2 year member add $30 3 year member add $55  

Total Fees:

Payment Method

Select One check enclosed MasterCard Visa  

Credit Card #:

Expiration Date: