ASNR

 

Application for International Outreach Member Status

Date: 8/22/2017

Applicants for International Outreach Member status are:

Radiologists/Neuroradiologists in developing countries with an annual per-person GDP of $10,000 or less . Click the Country field below to see the list.

PART I. Applicant Information:

First Name Middle Last Name
Degree Title

Home:

Address City State/Province
Country Zip/Postal Code Phone
Work:
Institution Department
Present Position (i.e. academic neuroradiologist, neuroradiologist in private practice, etc.)
Address City State/Province
Country Zip/Postal Code
Phone Fax Email (Preferred e-mail) A value is required.
PART II. Certification:
If you are board certified, please specify board name: Board Certification Date (mm/dd/yy) A value is required.Invalid format.(mm/dd/yy)

 

PART III. Training and Fellowship:

Radiology Residency ACGME or PCPSC-accredited Radiology Training Program: (select)
From Date: A value is required.Invalid format. (mm/dd/yy) To Date: A value is required.Invalid format. (mm/dd/yy)
Institution Residecy Training Director Training Director Tel Training Director Email
Neuroradiology Fellowship ACGME or PCPSC-accredited Radiology Training Program: Yes No (please indicate)
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

 

PART IV. Sponsor Information:

The sponsor must be a current ASNR member holding Senior or Member status.
Sponsor's Name

PART V. Credit Card Authorization for Membership Dues in USD $100.00

Credit Card Type Credit Card Number
Expiration Month Expiration Year Credit Card Holder