NEW MEMBER APPLICATION Preferred contact informaon (please print) Name: _____________________________________________ Designaon: ___________________________________________ Title: ______________________________________________ Company: _____________________________________________ Company Address: __________________________________________ City: ________________ State: ________ Zip: __________ Home Address: _____________________________________________ City: ________________ State: ________ Zip: __________ Primary Phone: _______________________ Mobile: _______________________ Birthdate: ________ / ________ / ________ Primary Email: _____________________________________________ Preferred mailing address: Home Company Secondary Email: ___________________________________________ Tell us more about yourself on page 2 of this applicaon Membership Dues Opons Member Benefits □ Check/money order enclosed, payable to AHRA □ Please charge my: □ Visa □ MasterCard □ American Express □ Discover Card #: _________________________________________________________ Expiraon Date: ____________________________________ □ Authorizaon for MONTHLY AHRA membership dues payment: By signing below, I authorize AHRA to automacally debit the credit card listed above in the amount of $17.50 monthly for 12 payments and $17.50 monthly thereaſter unl either party nofies the other in wring that they wish to cancel. Signature: ________________________________________________________________________________ Date: __________________ Radiology Management , renowned peer reviewed journal Free CE credits in the Online Instute Industry Data and Metrics AHRA Connect and the Forum: Popular online community and discussion groups Discounts on all products and meengs Online Resources: News, jobs, policies, and member directory Free Local Meengs Volunteer Opportunies Scholarships and Grants: Several financial assistance programs 1 Year Membership Dues $200.00 Membership is changing to a calendar year billing cycle. The price above reflects a paid through date of December 31. 1 Year Membership Dues $17.50/mth paid monthly* By choosing this option you agree to 12 monthly payments of $17.50 with automatic annual renewal on January 1. AHRA Educaon Foundaon Voluntary Contribuon: $ _____________ Your voluntary contribution to the AHRA Education Foundation is deductible as a charitable contribution. TOTAL: $ _____________ Join today online at www.ahra.org or return form to: AHRA, 490-B Boston Post Rd, Ste 200, Sudbury, MA 01776 Fax: 978-443-8046 or Email: [email protected]PAYMENT OPTIONS 490-B Boston Post Road, Suite 200, Sudbury, MA 01776 Toll Free: (800) 334-2472 Phone: (978) 443-7591 Fax: (978)443-8046 Email: [email protected]Web: www.ahra.org
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Membership Dues Options Member enefits...Free Local Meetings Volunteer Opportunities Scholarships and Grants: Several financial assistance programs 1 Year Membership Dues $200.00 Membership
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1. Is your organization (select one): □ A stand-alone facility □ Part of a multi-hospital system 2. Organization status (select one): □ Not-for-profit □ For profit □ Government 3. Type of employer (check all that apply):
Hospital Non-Hospital □ Academic (medical school affiliated) □ Imaging center □ Pediatric □ Multi-specialties physician office (not radiology) □ Long-term care □ Primary care clinic □ Community □ Radiologist private office □ Rehabilitation (greater than 75% patients) □ Mobile service □ Multiple hospitals □ Commercial □ Multiple facilities □ Consultant 4. Licensed hospital bed size (if applicable):
□ ASRT □ ARIN □ SDMS □ CLMA □ RBMA □ SIIM □ SNM □ ACHE □ Other (please specify) ______________________________________________________________________ 9. Years of responsibility in level:
________ Administration/management at one or multiple dept/facilities ________ Supervisor ________ Other (please specify) ________________________________ ________ Chief technologist 10. Current title (please select most relevant):