Student Membership Application






	I hearby make application for membership in the OHIO SOCIETY OF RADIOLOGIC TECHNOLOGISTS. If accepted, I agree to support the Code of Regulations of the Society and to conform to the code of ethics adopted by the Society. PLEASE FILL IN ALL BLANKS PRINT & MAIL FORM WHEN COMPLETED (All information will be treated as confidential) NAME (As you wish your name to appear on your certificate.)

First & Middle Name:
Last Name:
Birthmonth & Year
Email Address:
Gender:	Male Female
Home Address:
City:
State & Zip Code:
School:
City and Zip
Expected Graduation Date (month/year):
Home Phone:
Work Phone:
Cell Phone:
County:
Section:
Yes No	Interested in running for an OSRT board position?
Yes No	Interested in serving on an OSRT committee?
Fees for student membership in the Ohio Society of Radiologic Technologists: $30.00 (Note:Student memberships are valid through graduation from an approved Medical Imaging Program)(Credit card or check payments accepted-fill in below)

Expiration Date:
Student Signature:


	Faculty Signature & Date:

Please make check or money order payable to:
Ohio Society of Radiologic Technologists. If the application is not accepted, the entire amount will be refunded.

Mail this application along with the remittance to:
Dave Whipple, R.T.(R)
1985 Preston Avenue
Akron, Ohio 44305
Toll free (866) 405-OSRT (6778)
(Fax) (866) 405-OSRT (6778) or (330) 784-9042
osrt@neo.rr.com