ASPNRASPNR

Membership Application

Date: 6/26/2017

Apply for:

Indicate all the Societies in which you are a member:

PART 1. Applicant Information:
First Name Middle Last Name
Degree Title

Home:

Address City State
Country Zip Phone
Work:
Institution Department
Present Position (i.e. academic neuroradiologist, neuroradiologist in private practice, etc.)
Address 1 Address 2
City State
Zip
Country Phone Fax
Email (Preferred e-mail)
State percentage of time currently involved in Neuroradiology: %
Pediatric Neuroradiology: %

PART 2. Neuroradiology Fellowship Training:

Neuroradiology Fellowship 1st year:
(select)
From Date: A value is required.Invalid format. (mm/dd/yy) To Date: A value is required.Invalid format. (mm/dd/yy)
Institution Residency Training Director Fellowship Director Tel Fellowship Director Email
Neuroradiology Fellowship 2nd year: Same as above
(select)
From Date: A value is required.Invalid format. (mm/dd/yy) To Date: A value is required.Invalid format. (mm/dd/yy)
Institution Fellowship Training Director
Fellowship Training Director Tel Fellowship Training Director Email

A value is required.PART 3. Board Certification:

Check one of the following certification (below): Please select, if other, please Specify:
Board Certification Date (mm/dd/yy)

PART 4. Residency Training:

Type of Residency From Date: (mm/dd/yy) To Date: (mm/dd/yy)
Institution Residency Training Director
Residency Training Director Tel Residency Training Director Email

PART 5. Sponsors:

if you do NOT belong to any of the societies listed above, please provide two (2) sponsors. Sponsors must hold ASPNR Member status, or the equivalent from any of the societies mentioned. All sponsors must be familiar with the reputation and qualifications of the applicant and his/her involvement or interest in Pediatric Neuroradiology.
Sponsor 1 Name Sponsor 2 Name
Sponsor 1 Institution Sponsor 2 Institution
Sponsor 1 Tel Sponsor 2 Tel
Sponsor 1 Email Sponsor 2 Email
Please note - all applicants for Member status must provide a copy of their Radiology Board or Subspecialty Certificate in Neuroradiology.

PART 6. Membership Dues:

 
1st Qtr.
2nd Qtr.
3rd Qtr.
4th Qtr.*
Category
Annual Dues
Jan-Mar
Apr-June
July-Sept
Oct-Dec
Member
$125 + $50 application fee
$175
$132
$88
$175
Associate
$75
$75
$56
$38
$75
In-Training (Neuroradiology Fellow)
$0
$0
$0
$0
$0

* When dues are paid during the 4th quarter, membership is valid through the end of the following year.

Dues Amount $ (Enter your prorated dues amount)
Credit Card Type Credit Card Number
Expiration Date / Credit Card Holder