KSRT Membership Form

The Kentucky Society of Radiologic Technologists Inc.
P.O. Box 213
Morehead, KY 40351

MEMBERSHIP CATEGORIES
Active- ARRT registered radiographers who are ASRT members
Associate- ARRT registered radiographers who are *not* ASRT members and/or licensed radiation operators
Student- Individuals enrolled in an accredited educational programs; ineligible for CE credit
Life- Members who have rendered unusual service to the Society and have been elected to this position by majority vote (annual dues waived)
Honorary- Individuals honored because of contributions made to the profession and elected to this position by majority vote; unable to vote or hold office (annual dues waived)
Supporting- Individuals interested in promoting the KSRT but are ineligible for active or associate membership; unable to vote or hold office

Member Information

Please Fill in the information below to join KSRT.

* First Name

* Last Name

KSRT Member Number

* Address 1

* Membership Type

Address 2

* City

* State

* Postal Code

Are you a member of the ASRT?

Yes

No

Member Number

State Certification Number

* Phone

* Email Address

* You may contact me via regular mail with information and announcements.

Yes

No

* You may contact me via email with information and announcements.

Yes

No

* Would you be interested in running for a KSRT office?

Yes

No

Would you be interested in serving on a committee?

Yes

No

* Indicates Response Required

Active	Associate	Student
Life	Honorary	Supporting