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2012 MEMBERSHIP APPLICATION FOR REGISTERED TECHNOLOGISTS

PERSONAL CHECK OR USPS POSTAL MONEY ORDER PAYMENT BY MAIL

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Date *
New membership or Renewal? *
Membership level *
PSRT Number
First Name *
Middle Initial / Name
Last Name *
Address 1 *
Address 2
City *
County *
State *
Zipcode *
Home Phone *
Work Phone
WorkPhone Ext.
Email Address *
Degree *
Primary Credentials *
Certifications *
Radiography
Nuclear Medicine
Radiation Therapy
Magnetic Resonance Imaging
Computed Tomography
Mammography
Interventional Radiography - Cardiac
Interventional Radiography - Vascular
Quality Management
Bone Densitometry
Sonography
Sonography - Breast
Sonography - Vascular
Radiologist Assistant
Education
PACS
Retired
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