Last Name (required):

First Name (required):

Certification Agency (required):
—Please choose an option—ARDMS – American Registry for Diagnostic Medical Sonography®ARRT – American Registry of Radiologic Technologists®NMTCB – Nuclear Medicine Technology Certification Board®Kapiolani Community College Student

Certification or Student No. (required):

Certification Agency:
—Please choose an option—ARDMS – American Registry for Diagnostic Medical Sonography®ARRT – American Registry of Radiologic Technologists®NMTCB – Nuclear Medicine Technology Certification Board®

Certification No.:

Certification Agency:
—Please choose an option—ARDMS – American Registry for Diagnostic Medical Sonography®ARRT – American Registry of Radiologic Technologists®NMTCB – Nuclear Medicine Technology Certification Board®

Certification No.:

ASRT No. (if applicable):

I wish to be contacted about future events and CE seminars
YesNo

Mailing Address (required)

Address 1:

Email (required):

Address 2:

City:

State:
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip:

Island:
—Please choose an option—Hawai'iKaho'olaweKaua'iLana'iMauiMoloka'iNi'ihauO'ahuN/A

Are you interested in volunteering or assisting the HSRT with administrative procedures at CE seminars or volunteering on your respective Island?
YesNo

How did you hear about HSRT?

Please submit this form electronically by selecting the SUBMIT button below or mail it to:

Hawaii Society of Radiologic Technologists
PO Box 1675
Pearl City, HI 96782