Membership Application

Membership category applied for:

Date: 1/19/2018

1. Applicant Information

First Name Middle Last Name Degree
Address City State
Country Zip Phone
Institution Department Address
City State Zip
Country Phone Fax
Email (Preferred e-mail) A value is required.
2. Indicate the Societies in which you are a member:

If you are a member of any of the societies listed under #2 (above), proceed to #9 to agree on ASFNR's constitution and enter the appropriate amount of prorated dues. You do NOT need to complete the other sections of this application. Otherwise you must complete all portions of this application, provide the required documentation and prorated dues. 

3. Indicate if you belong to the following societies:

4. Sponsorship:

Sponsors must be members in good standing, holding ASFNR Member status, or the equivalent from any of the societies mentioned in #2. 
All sponsors must be familiar with the reputation and qualifications of the candidate and his/her involvement or interest in functional neuroradiology. 

5. Certification:

Subspecialty Certification (formerly CAQ) Subspecialty

6. Medical (or Graduate) Education:

7. Post-Graduate Education (Internship, Residency, Fellowships) (including Institution Completion dates):

A value is required

8. Practice Setting:

9. I agree to abide by the ASFNR Constitution and any revisions thereof:

10. Credit Card Authorization for Membership Dues:
ASFNR Prorated dues include application fee
1st Qtr.
2nd Qtr.
3rd Qtr.
4th Qtr.*
Annual Dues
$125 + $25 application fee
$50 + $25 application fee
Study Groups are an additional $10 each (not prorated) – add $10 for each group membership, and indicate the group: 
* When dues are paid during the 4th quarter, membership is valid through the end of the following year.
Dues Amount $ (Enter your prorated dues and study group dues amount)
Credit Card Type Credit Card Number
Expiration Month/Year / Credit Card Holder