APPLICATION FOR MEMBERSHIP
PLEASE
TYPE OR PRINT
AND
RETURN TO THE SECRETARY OF THE LIRS
Date_________________
I, the undersigned, hereby apply
for membership in the LONG ISLAND
RADIOLOGICAL SOCIETY, and if
accepted, agree to support the by-laws of this Society.
The accompanying check is payment
for dues for the year.
If not accepted as a member the
money is to be returned to me.
Type of membership:
€
Full €
Associate €
Resident €
Other Specify:_______
Name in full______________________________________________________
E-mail Address _____________________________________________
Mailing
Address_____________________________________________
Town__________________________State_________Zip
Code_______
Telephone
Number___________________________________________
Office
Address______________________________________________
Town__________________________State_________Zip
Code_______
Office telephone
number_______________________________________
Place and date of
birth________________________________________
Medical College and date of
graduation___________________________
Residency and
dates_________________________________________
Date and number of New York
license____________________________
Past
and present hospital appointments and affiliations:
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Diplomate, American
Board of Radiology in_______________________
Date of
Certification__________________________________________
Membership in following
County Medical Society____________________
I am €,
am not €
a member of the New York State Chapter of the American College of Radiology.
I hereby designate the
following local society for voting purposes in the New York State Chapter of the
ACR__________________________________
Government
service__________________________________________
Is practice limited to
radiology?_________________________________
Names of associates in
practice_________________________________
__________________________________________________________
Publications________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Sponsored by 1.________________________________________________________ 2.________________________________________________________
Signed:___________________________________________________
Date:_____________________________________________________
Approved by Executive
Committee_______________________________
Application voted
upon________________________________________
Letter of notification
sent_______________________________________