THE NORTHWEST CHAPTER
of the
AMERICAN ASSOCIATION OF PHYSICISTS IN
MEDICINE
Application for Membership
Type: Full
_____ Student _____ Emeritus _____
Name _______________________________________________________________________
Institution
____________________________________________________________________
Department
___________________________________________________________________
Street Address ________________________________________________________________
City, State, ZIP
________________________________________________________________
Phone
_______________________________________________________________________
FAX ________________________________________________________________________
E-Mail
______________________________________________________________________
Education:
1. Institution, Major, Dates,
Degree _______________________________________________________________
____________________________________________________________________________________________
2. Institution, Major, Dates,
Degree _______________________________________________________________
____________________________________________________________________________________________
Experience:
1. Employer, Title, Dates
_______________________________________________________________________
____________________________________________________________________________________________
2. Employer, Title, Dates
_______________________________________________________________________
____________________________________________________________________________________________
Memberships in other Societies _________________________________________________________________
Other
Qualifications (Certifications, etc.)
_________________________________________________________
______________________________________________________________________________________________
Current Scientific Interests
related to Medical Physics (required for non AAPM members) ______________
______________________________________________________________________________________________
______________________________________________________________________________________________
Please send your completed application to secretary/treasurer, Trevor M. Fitzgerald, whose contact information appears on our Officers web page.