Membership Application Member DetailsName* First Last CredentialsAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* ARRT License #ASRT Membership #Membership Type*$40 1 year- Active RT (currently employed as an RT)$60 2 year- Active RT (currently employed as an RT)$40 1 year- Active Non-RT (Wyoming Restricted/Limited License)$60 2 year- Active Non-RT (Wyoming Restricted/Limited License)$40 1 year- Supporting Member (Commercial Reps)$35 1 year- Inactive RT (Not actively employed in Radiology as an RT)$30 2 years- Student (Full time radiology students)$0 1 year (one time)- Graduating StudentNONE- select if paying for multiple studentsStudent Membership OptionsStudent 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)Casper CollegeLaramie County Community CollegeWeber StateOtherGraduation Date (students only) Date Format: MM slash DD slash YYYY Student NamesList the name of each student if you're purchasing more than one membership.Commercial Rep InfoCompany Name or Imaging Facility (commercial reps only)Membership PreferencesCathode*Opt for our e-newsletter and help the WSRT save money!Yes, e-newsletter pleaseNo, I'd like to receive the cathode in the mailMembership Correspondence*how would you like to receive your WSRT membership information?electronic (email)paper (sent in the mail)bothVolunteering*Would you be interested in serving on the board or volunteering on a committee?YesNoNot right now, I'll contact you when I'm readyWho 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. * CommentsThis field is for validation purposes and should be left unchanged. Prefer to use our paper application? Print and mail it in, or scan it and upload here! Paper Application Upload your Application