ASNR

Senior/Senior International Membership Application

Date: 5/25/2017

Apply for:
Indicate if you currently hold ASNR membership in either category:

Applicants for Senior status must:

  • Be a radiologist certified by the American Board of Radiology (ABR), The Royal College of Physicians and Surgeons of Canada (RCPSC), The American Osteopathic College of Radiology (AOCR), or other Board or Tribunal which, in the judgment of the Executive Committee, is of equivalent rank.
  • Have completed a one-year ACGME or RCPSC-approved fellowship program in Neuroradiology and passed the ABR Subspecialty Certification exam in Neororadiology.
  • Is engaged in active practice of neuroradiology and/or a subspecialty of Neuroradiology in a North American country, devoting at least 50% (exclusive of administrative duties) to the professional practice of Neuroradiology.
 

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:
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

You need a sponsor if you have not passed the ABR's Subspecialty Certification exam in Neuroradiology, and are not a member of the ASNR. The sponsor must be a current ASNR member holding Senior or Member status.
Sponsor's Name

 

PART V. Credit Card Authorization for Senior 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
Senior
$625
$625
$469
$313
$625
Senior International
$625
$625
$469
$313
$625
Senior (Military)
$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