ASNR

 

Application for Member Status

Date: 11/24/2017

Do you currently hold ASNR Member-in-Training status? Yes No

Applicants for Member status are:

Completed a 1-year ACGME or RCPSC accredited Neuroradiology fellowship program, but is not Radiology Board certified at this time, OR other radiologists, scientists (Master's degree or higher ([PhD]), and physicians with an interest in Neuroradiology, who do not meet the criteria for Senior or Senior International membership.

PART I. 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 City State Zip
Country Phone Fax
Email (Preferred e-mail) A value is required.
Percent of time devoted to Neuroradiology in present position A value is required.Percent %

PART II. Certification

Check one of the following certification (below): Please select, if other, please Specify:
If none, skip Part III and Part IV
Board Certification Date (mm/dd/yy) A value is required.Invalid format.(mm/dd/yy)

PART III. Training

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

You need a sponsor only if you do not currently hold an ASNR membership. Sponsor must currently hold Senior or Member status.
Sponsor's Name

PART V. Credit Card Authorization for Membership Dues

Prorated dues include application fee
1st Qtr.
2nd Qtr.
3rd Qtr.
4th Qtr.*
Category
Annual Dues
Jan-Mar
Apr-June
July-Sept
Oct-Dec
Member
$625
$625
$469
$313
$625
Member (1st year out of Neuroradiology Fellowship)
$375
$375
$281
$188
$375
Member (2nd year out of Neuroradiology Fellowship)
$575
$575
$431
$288
$575
Member(Military, Radiologists, and those outside of N.America)
$230
$230
$173
$115
$230

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

Dues Amount $ (Enter your prodated dues amount)
Credit Card Type Credit Card Number
Expiration Month Expiration Year Credit Card Holder