AEIRS Logo

Online Membership Application

This application is driven using PayPal. If you do not have PayPal you will not be able to complete this form.

The dues year for the Association of Educators in Imaging and Radiologic Sciences is April 1st to March 31st annually. New member applications received between January 1st and March 31st will be processed to include the remaining months in the current membership year as well as the upcoming membership year.

ALL FIELDS THAT ARE BOLD ARE REQUIRED. If you do not complete ALL bold fields an error may occur returning you to this screen which may appear empty. So, please fill out the application completely. Thank You

Application Date:
First Name:
Last Name:
Degree (Select highest degree category): Certificate
Associate Degree
Baccalaureate Degree - please specify:
Masters Degree - please specify:
Doctoral Degree - please specify:
Specify Other:
Credentials (Check all that Apply): RT(R)
RT(T)
RT(N)
RT(M)
RT(CV)
RT(CT)
RT(MR)
RT(QM)
RT(BD)
RDMS
CNMT
CMD
Specify Other:
Employer:
Title/Department:
Work Address:
City:
State:
Zip Code (zip+4): -
Country:
 
Home Address:
City:
State:
Zip Code (zip+4): -
Country:
 
Preferred Contact: Home
Work
 
Home Phone: (XXX-XXX-XXXX)
Work Phone: (XXX-XXX-XXXX)
Fax Number: (XXX-XXX-XXXX)
E-mail Address:
PRIVACY INFORMATION
It is the AEIRS policy to sell the mail list for mailings that contribute to knowledge regarding the profession. The list is not sold for recruitment or advertising purposes. May AEIRS release your mailing address? Yes No
If the AEIRS board approves a research survey from an AEIRS member to fellow AEIRS members, the board will release email addresses for this research project. May AEIRS release your email address? Yes No
May AEIRS list your Name, Employer, Work Phone, and Email Address in the Member Directory? Yes No