NASSAU SUFFOLK SOCIETY OF RADIOLOGIC TECHNOLOGISTS MEMBERSHIP APPLICATION 2007-2008 New Member _____ Renewal ____ Date ___________________ Name ____________________________________________ Send applications for Address _________________________________________ Membership to: Zip Code_______________ Phone #__________________ Robert Geiser E-mail ______________________ P.O. Box 302 Employer/School__________________________________ Centereach, New York Expected Graduation Date: Month____ Year____ 11720 ANNUAL MEMBERSHIP DUES: (Check one) _______Radiologic Technologist $30.00/Year _______Technical Representative $30.00/Year _______RT Student $25.00/ 2 Years Students must join before December 31 of their junior year to be eligible to participate in the scholarship exam, and other student activities, without additional fees. Membership is from date joined until graduation. -------------------------------------------------------------------------- 03/29/2008 CONFERENCE REGISTRATION: (CHECK ONE) Pre-Conferece On Site NSSRT Member Registration __$25.00 __$ 50.00 Non Member Registration __$65.00 __$130.00 RT Student member __$ 5.00 __$ 10.00 ST Student Non-Member Senior __$35.00 __$ 70.00 (ST Price includes Membership) Make check or money order payable to NSSRT and mail both Application and Check to: MS.Bonnie Healey RT, Treasurer 75 Pilgrim Lane Westbury, NY 11590

To become a member of the NSSRT  and/or Register for an upcoming conference, simply fill in this application (above), print it out and send it in with your check.

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