ASSRASSR Membership Application

Date: 10/19/2017

Apply for:

PART 1. Applicant Information:

First Name Middle Last Name Degree
Name of ASSR member who referred you (if applicable)
Home:
Address City State Country
Zip Phone
Work:
Institution Department
Address 1 Address 2
City State Country:
Zip Phone Fax
Email (Preferred e-mail)
Current practice devoted to Spine Radiology: %

PART 2. Indicate all the Societies in which you are a member: (if you are a member of any of the societies, proceed to the dues section at end of this application)

PART 3. Sponsorship: only applicants who do NOT belong to any socities listed above:

Sponsor Name Sponsor Institution Sponsor Tel
Sponsor Email

PART 4. Board Certification (Active member applicants need to be certified in Radiology by the ABR, RCPS or equivalent):

Board or Tribunal : Certificate Date:

PART 5. Fellowship Training or Postgraduate Education:

Institution 1 Program Director 1
Institution 2 Program Director 2 Completion Date: A value is required.Invalid format. (mm/dd/yy)

PART 6. Medical or Graduate Education:

Institution Degree

PART 7. Residency Training:

Institution Program Director Completion Date: A value is required.Invalid format. (mm/dd/yy)

 

PART 8. Membership Dues:

 
1st Qtr.
2nd Qtr.
3rd Qtr.
4th Qtr.*
Category
Annual Dues
Jan-Mar
Apr-June
July-Sept
Oct-Dec
Active
$135 + $25 application fee
$160
$126
$93
$160
Associate
$75
$75
$57
$38
$75
In-Training (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