Colorado Society Radiologic Technologists APPLICATION FOR MEMBERSHIP SS Number_____________________________ First Name _________________________ Middle Initial ___________ Last Name ______________________________________ Maiden Name______________________________________ Title (RTR, RTT, NMRT) _________________________________ Mailing Address ________________________________________________________________________________ City/State/Zip Code ________________________________________________________________________________ Email address: ___________________________________________ Work Phone ( ) _____________________ Home Phone ( )___________________ Present employment ________________________________________________________________________________ Employer Address ______________________________________________________________________________ PLEASE CHECK WHERE APPROPRIATE Certified In: Position Title: Educational Level: ( ) Radiography ( )Staff Technologist ( )Certificate ( ) Nuclear Medicine ( )Special Procedures ( )Associate ( ) Radiation Therapy ( )Director of Education ( )Baccalaureate ( ) Diagnostic Medical ( )Instructor Major __________________ Sonography ( )Manager Minor __________________ ( )Computed Tomography ( )Chief Rad. Tech. ( )Masters ( )Magnetic Resonance ( )Assistant Chief Major __________________ ( )Other (please specify) ( )Doctorate _______________________ Major __________________ Referred By:____________________________________ CSRT#_______________________ Work In: ( )Hospital ( )Clinic ( )Private Office ( )School of Rad. Tech. ( )Commercial Company ( )Not employed ( )Other (please specify) __________________________ THIS SECTION FOR ACTIVE AND ASSOCIATE MEMBERS ONLY ARRT Number _____________________ Date Certified by ARRT ___________________ License Number _____________________________________ State ___________________________ ASRT # ____________________________________ Other credentials: ________________________________________________________________________________ THIS SECTION FOR STUDENTS ONLY Verification of Student status must be attached with the following information: Name of Program ________________________________________________________________________________ Complete address ________________________________________________________________________________ Accredited by (CAHEA-AMA) Anticipated graduation date: _____________________________________________ I hereby make application for membership in the Colorado Society of Radiologic Technologists and agree to support the bylaws of the Society and my chosen profession. I enclose dues with this application. I understand that I shall be entitled to the rights and privileges of membership according to my classification in the bylaws. Signature of Applicant Date Accepted ___________Received ________________ Cassette Editor Notified _______Ledger Comp. __________ Certificate, Bylaws mailed __________________________ Form downloaded from: http://www.csrt.net MAIL TO: Marilyn Walker RTR C.S.R.T. Executive Sec. 1220 So. Pennsylvania Denver, CO 80210 MEMBERSHIP ELIGIBILITY REQUIREMENTS A candidate for CSRT membership shall submit a completed application accompanied by the required fees. ACTIVE MEMBERS Active members are technologists certified by and in good standing with the American Registry of Radiologic Technologists (ARRT) and the American Society of Radiologic Technologists. Membership Fee - $35.00/yr. TECHNOLOGIST ASSOCIATE MEMBERS Technologist Associate members are technologist certified by and in good standing with the ARRT but not members of ASRT. Membership Fee - $45.00/yr. COMMERCIAL ASSOCIATE MEMBERS (INDIVIDUAL AND/OR GROUP MEMBERSHIPS) Those persons who are or have been employed in the technical or commercial aspects of medical imaging modalities and do not qualify for Active membership Membership Fee - Individual - $20.00/yr Group - 1 or more individuals - $50.00/yrs. INACTIVE MEMBERS Inactive members are former members certified by and in good standing with the ARRT, who are no longer actively engaged in the profession of Radiologic Technology and who have applied for Inactive membership status. Membership Fee - $15.00/yr. SUPPORTING ASSOCIATE MEMBERS Those individuals not registered technologists or members of ASRT. Membership Fee - $45.00/yr. STUDENT MEMBERS Those students enrolled in Radiologic Technology programs of at least 24 months duration which are approved by the CAHEA-AMA or by a state Radiologic Technology Licensure Board. Eligibility for this category shall terminate on completion of, or discontinuation of such education. Student members whose current dues are paid, may transfer to Active or Associate status (according to their eligibility) by remitting the difference between Student and Active or Associate dues with a letter requesting the transfer, and verification of certification or licensure. Student members who have completed their educational program and are awaiting the results of credentialing examinations may remain student members until such results are available, for a period not to exceed six months. Credentialed technologists returning to an educational program for a higher degree or credential are not eligible for student status and must apply for Active or Associate status according to their eligibility. Once certified or licensed in any modality, the individual is no longer eligible for student membership. Membership Fee - $20.00/yr. RESIGNATION Any member shall have the privilege of resigning by means of written communication, providing all dues and other indebtedness to the Society have been satisfied. MEMBERSHIP FEES 1) Application and membership fees for all categories of membership shall be established by the Executive Board subject to a 2/3 vote of the members present and voting at the CSRT Annual Executive Board Meeting. 2) Dues include a subscription to the professional journal, Cassette Gazette. 3) Any intent to change the dues structure shall be communicated in writing to all voting members a minimum of 60 days prior to the Annual Meeting. 4) No member who is in arrears for dues shall vote or hold office, or be entitled to receive reports of the transactions of the Society. It shall be the duty of the Executive Secretary to remove from the rolls of membership the name of any person who is in arrears for more than 90 days, Any member dropped from the rolls of membership for non-payment of dues may be reinstated only upon filing a new application and paying the regular fee as a new member,