Society of Atherosclerosis Imaging - Membership Application

Membership Application

Contact Information
Name:
Title:	MD DO PhD Other
Preferred mailing address:	Business Home
Business Address:

City:
State:
Zip:
Business Phone:
Business Fax:
Pager:
Mobile/Cellular:
Home Address:
City:
State:
Zip:
Email:
Recommended by:

Annual Membership Fees:
(payable to: Society of Antheroscierosis Imaging & Prevention)

Physician / Ph.D. — $200
Other — $100 (Student, Post-doc*, Fellow*, Gov. Employee, Technologist, Nurse, Physician Assistant)
*Please fax / send a letter of eligibility from a qualifying institution

Print this form, complete and mail with check (US Funds) made
payable to SAIP to:

Society of Atherosclerosis Imaging and Prevention
Attn: Lawrence H. Leong, Executive Director
8601 Aqueduct Road
Potomac, MD 20854