SCMR: Membership - Application Form

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Last updated: 04/30/08

SCMR Membership Application

Name:
Degree(s):
Current Position
Name of Affiliation
Address:

City:
State:
ZIP:
Country:
Office Phone:
Fax:
Email:	(type your name here if you don't have an email address)

Membership Category:

Primary Specialty (select one):

Cardiologist	Radiologist
Non-Physician Scientist	Nuclear Medicine
Physician (other specialty)	Technologist/Allied Health
Non-medical

ACTIVITIES ENGAGED IN: (Check all that apply)
Admin/Management/Industry Cardiac CT Clinical Cardiology
Cardiothoracic Radiology Diagnostic CMR Echocardiography
General Radiology General Ultrasound Hospital
Internal Medicine Interventional CMR Interventional Radiology
Invasive Cardiology Invasive Radiology Nuclear Medicine (A)
Pediatrics PET Imaging Private Practice
Research Stress CMR Teaching
University

Membership Registration:

Please check the category that best fits you: Regular Member ($225/person $265 for late renewal) Trainee Member ($60/person $85 for late renewal) Technologist/Allied Health Member ($60/person $85 for late renewal) Emeritus Member ($60/person $85 for late renewal)
Method of Payment MasterCard Visa American Express Check (made payable to SCMR)
Credit Card Number
Expiration Date
Name on Card
Alternatively, you can pay by check made payable to SCMR. Your Signature: (if faxing or mailing the form)

Please mail/fax your completed membership registration form and payment to: Society for Cardiovascular Magnetic Resonance 19 Mantua Road Mt. Royal, NJ 08061 Phone: (856) 423-8955 Fax: (856) 423-3420 E-Mail: membership@scmr.org

19 Mantua Road, Mt. Royal, NJ 08061, U.S.A.
Phone: (856) 423-8955 - Fax: (856) 423-3420 - E-Mail: HQ@SCMR.org