The Mammographers Society of Georgia
Membership Application
Fiscal Year July 1 – June 30
I hereby make application for membership in The Mammographers Society of Georgia and agree to support the bylaws of the Society.
Please check the appropriate category: Membership fees:
_____New Member application $20.00 Active Members (ARRT)
_____Renewal application $20.00 Associate Member
_____Change of address, name, etc $10.00 Student Member
Name_____________________________________________________________
Address___________________________________________________________
Phone - Home________________Work_______________Cell________________
Email Address______________________________________________________
PRIMARY PRACTICE ARRT REGISTERED
__Mammography ___Radiology
__CT__Educator ___Mammography
__Radiology ___Rad Therapy
__Management ___Nuclear Medicine
__Sonography ___Sonography
__MRI ___QA-QM
Check all that Apply
Would you like to be more involved in the MSG by serving on a committee or running for office? Yes_____ No_____ If yes, area of interest___________________
Are you a member of the GSRT? Yes________No_________ Would you like to have information sent to you? Yes____ No____
Make Check or Money order payable to
MSG & mail to:
Mammographers Society of GA, PO Box 664, Lebanon, GA 30146
FOR MSG USE:
Dues Received (Date)______
Paid by cash__Ck__MO____
Amount______
