New member_____/ Renewal_____

FULL NAME ___________________________________________________________

HOME MAILING ADDRESS _____________________________________________

____________________________________________________

HOME PHONE NUMBER _____________________________________

EMAIL ADDRESS ___________________________________________

PLACE OF EMPLOYMENT _____________________________________________

WORK PHONE NUMBER _____________________________________

CHECK ALL REGISTRY CATEGORIES THAT APPLY TO YOU:

• _____ Radiography
• _____ Radiation Therapy
• _____ Nuclear Medicine

ARRT REGISTRY# __________________

STATE LICENSURE# __________________
(Please submit copy of ARRT and TDH wallet card or certificate for verification)

CURRENT MEMBERSHIPS:

• ASRT ____yes ____ no
• TSRT ____yes ____ no

SUBMIT APPROPRIATE FEES ACCORDING TO MEMBERSHIP STATUS:

• ____Annual active membership-$5.00
• ____Annual student membership-$5.00

Signature_____________________________________ Date______________