GEORGIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS, INC.
MEMBERSHIP APPLICATION

P.O. Box 767369

Roswell, GA  30076-7369

Office:  770-475-5216     Fax:  770-475-5618

 Email: membership@gsrt.org

If this is a renewal, enter your Name, Today’s date, and your Social Security Number. Please update personal data and if needed provide Method of Payment. Life and Honorary members please also complete and return. This will help to keep our records current.

Contact Information
Full Name:
Social Security Number:
Today's Date:
DOB:
Title: (Example: RT (R)(CT) etc.)
Phone: (Please include your Area Code)
Work Phone: (Please include your Area Code)
E-Mail:
Work Modality:
Address:
 
City:
State:
Zip Code:
Credit Card Billing Information (Check to use Contact Information: )
Full Name:
Phone: (Please include your Area Code)
Address:
 
City:
State:
Zip Code:
Credit Card Number  
Expiration Date:
Card Type MasterCard Visa
 

Are you joining from recommendation by a co-worker or friend who is a GSRT member? If so, please list their name so that we may send them a thank you for the referral and enter their name for the Silver award.

Each year, the newly elected President chooses committee chairs and committee members from a list of GSRT members who have stated that they are interested in working on a committee.  If you would like for your name to be placed on the list, please answer YES to the following.

Are you interested in working on a GSRT committee?  YES

Membership Fees - Dues are non- refundable
Membership Type  
$35 ACTIVE - (ARRT Certified and working as a technologist or management in field)
$35 SUPPORTER - (Commercial Rep. etc. )
$12 STUDENT - (Actively pursuing certification in a radiologic science modality)
     
Price $
Please "Calculate" your membership fees before continuing.

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