Membership Application

Member Details
Name*
First Last
Credentials
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
ARRT License #
ASRT Membership #
Membership Type*
Student Membership Options
Student Rate (choose if paying for multiple students)
2 year membership // Make sure you choose "NONE" in the drop down above so you aren't charged for an extra membership
Price: $30.00 Quantity:
Education Facility (students only)
Graduation Date (students only)
Student Names
List the name of each student if you're purchasing more than one membership.
Commercial Rep Info
Company Name or Imaging Facility (commercial reps only)
Membership Preferences
Cathode*
Opt for our e-newsletter and help the WSRT save money!
Membership Correspondence*
how would you like to receive your WSRT membership information?
Volunteering*
Would you be interested in serving on the board or volunteering on a committee?
Who can we thank for referring you?
First Last
Headshot
(OPTIONAL) Please load a photo of yourself for your file so we can put a face to the name.
Total
$0.00
Privacy*
- By using this form you agree with the storage and handling of your data by this website.
Comments
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Prefer to use our paper application? Print and mail it in, or scan it and upload here!