THE EAST BAY DISTRICT OF THE CALIFORNIA SOCIETY OF RADIOLOGIC TECHNOLOGISTS Application for Membership Name: ___________________________________________________________ Address: ________________________________________________________ City: ___________________________________ Zip Code: _____________ Phone: Day: ___________________ Eve: ____________________ Fax: ___________________ CSRT Member? Yes___ No___ Member # __________ ASRT Member? Yes___ No___ Member # __________ Worksite_________________________________________________ Are you willing to be a contact person for your worksite? Yes___ No___ What area do you work in? Routine___ CT___ Angio___ US___ MRI___ Mammo___ OTHER___ Why did you join the District? _____________________________________ ____________________________________________________________________ Yearly Dues $10.00 Meeting Fees: Members $5.00 Non-Member $7.00725 Lincoln Avenue * Brentwood, CA 94513 * (510) 256-1491