Rio Grande Chapter of the Health Physics Society
Membership Application/Renewal Form

 

Last Name

First Name

MI

Suffix
Name to go by:

New Application  $5.00  Annual Renewal $15.00

Employment Information

Employer:

 

Mailing Address Line 1:

 

Mailing Address Line 2:

 

City:

    State:    ZIP: 

Work Phone:

    Work Fax:

Work E-mail:

 

Job Title:

 

Occupation:

 

Area of expertise (i.e., transportation, training, medical, dosimetry etc.):

 

Home Information

Home Address Line 1:

 

Home Address Line 2:

 

City:

    State:   ZIP:

Home Phone:

    Home Fax:

Home E-mail:

 

Preferred E-mail address to receive RGC-HPS news, etc. Home        Work
Publish my name/address in the chapter's member directory:
Use:
 Yes           No
Home        Work

RGC-HPS Affiliate Members (Vendor's) may contact me.
Use:

Yes           No
Home        Work
Educational Information

Highest Degree:

 

Course of Study:

 

Memberships

Are you a:

  National Society member?     Certified HP?     Member of the NRRPT?

Send the completed application form and your remittance to:
 RGC HPS
P.O. Box 51686
Albuquerque, NM 87181-1686