Walk-through-the-week Overview - ismrm

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ISMRM MEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION DEADLINE: In order to qualify for member
rates at the 2005 Annual Meeting, your completed application form, along with
sponsor signature, payment of membership dues, one copy of your CV, and, if
applicable, student verification letter must be received before or at the time of
registration for the meeting.
Mail all materials to: International Society for Magnetic Resonance in Medicine
Membership Director
P.O. Box 45690
San Francisco, California
94145-0690, USA
QUESTIONS? Please Contact ISMRM at: Telephone: +1 510 841 1899
Fax: +1 510 841 2340 E-mail: info@ismrm.org Website: www.ismrm.org
All Applicants, please indicate professional affiliations (check as many as apply):
AAN AAPM ACR ARRS ASNR ASRT ESMRMB JSMRM
RSNA SNM Other ( ________________________ )
All Applicants, please indicate professional classification:
Basic Scientist Clinical Scientist Industrial Management Radiologist
Educator Radiology Support Personnel
Other ( ________________________ )
All Applicants, please indicate your BASIC SCIENCE primary field of endeavor:
Biochemistry Biophysics Chemistry Engineering Mathematics
Physics Physiology Other ( ________________________ )
All Applicants, please indicate your CLINICAL SCIENCE primary field of endeavor:
Cardiology Internal Medicine Neurology Psychiatry Radiology
Surgery Other ( ________________________ )
Applicants for Full Membership, please indicate the year started and extent of your
involvement with MR.
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Please confirm completion of the required steps:
All Applicants: Completed Application One (1) Copy of Current CV
Signed Endorsement Membership Dues Study Group Choice(s) [optional]
Journal Selection
Full Member Applicants: List of MR-related publications (if available)
Student Applicants: Letter of Student Verification
Associate Member Applicants: Income Verification Form (Please request from ISMRM)
Applicant Signature: ___________________________________ Date: _____________
Sponsor Signature: _______________________________________________________
Sponsor Name (please print): _______________________________________________
ISMRM makes its member list available to a few carefully screened companies.
If you do not wish to be included, check here.
Please print or type.
Name _______________________________________________________________________________________
Family Name Given/First Name Middle Degree
Qualifications (circle): M.D. (Doctor of Medicine or equivalent) Ph.D. (Doctor of Philosophy or equivalent) M.D./Ph.D. Other ____________
Honorific (circle): Dr. Prof. Mr. Ms. Mrs. Other ______________________________
Institution Address ___________________________________________________________________________
_____________________________________________________________________________________________
Street
_____________________________________________________________________________________________
City State/Province Country Postal Code/Zip+4
_____________________________________________________________________________________________
Telephone Fax Number Electronic Mail Address
Home Address ________________________________________________________________________________
_____________________________________________________________________________________________
Street
_____________________________________________________________________________________________
City State/Province Country Postal Code/Zip+4
_____________________________________________________________________________________________
Telephone Fax Number Electronic Mail Address
IMPORTANT: Please send my mail to: Institution Address Home Address
MEMBERSHIP DUES: Dues must be paid when the application is submitted.
Full Member (With one journal) Journal Choice: MRM JMRI ..................................... US $225.00
Full Member (With both journals) ................................................................................. US $325.00
Student Member (without journal) ................................................................................ US $ 25.00
Student Member (With one journal) Journal Choice: MRM JMRI............................... US $125.00
Student Member (With both journals) ........................................................................... US $225.00
Associate Member (Choose one electronic-only journal MRM JMRI) .......................... US $ 25.00
I prefer to receive my journal(s): In print form & electronic form In electronic form only
Study Groups:
Brain Function Cardiac MR Diffusion and Perfusion MR Dynamic NMR Spectroscopy
High Field Systems and Applications Hyperpolarized Noble Gas MR Interventional MR
Molecular and Cellular Imaging MR Engineering MR Flow and Motion Quantitation MR of Cancer
MR in Drug Research Musculoskeletal Imaging Psychiatric MRS and MRI White Matter Diseases
Study Group Dues (No charge for Emeritus or student members): # of Study Groups__ x US $10.00 = _____________
METHOD OF PAYMENT
Check payable to ISMRM is enclosed.
VISA MasterCard AMEX
Total Amount Enclosed US $ _____________
Credit Card # ________________________________________________ Expiration Date _________/__________
(Required)
Cardholder Signature __________________________________________ Amount US $ ______________________
(Required)
Billing Street Address _________________________________________ Billing Zip/Postal Code ______________
(Required)
MM/YY
(Required)
(Required)
(Required)