SROA: MEMBERSHIP FORM

SROA APPLICATION FOR MEMBERSHIP

NAME
Gender:	Female Male
First Name:*
Middle Initial:
Last Name:*
Degrees:

PERSONAL INFORMATION
Age Range:	22-34 35-44 45-54 55 and above
Home Address:*
City:*
State or Providence:*
Zip/Postal Code:*
Country:*
Home Telephone:*
Fax:*
Where do you wish your mail to be sent?:* Home Work

CURRENT POSITION
Title:*
Start Date: (MM/DD/YY)*
Organization:*
Address:*
City:*
State:*
Zip/Postal Code:*
Country:*
Business Telephone:*
Fax:*
E-mail:*
Institution is:*	Community Hospital Freestanding University Based Other (Please Specify)

Would you be interested in serving on a committee? If yes, please select one from the drop down list:

Professional Work/Education History *

Total years in Healthcare Administration: Radiation Oncology Administration:

My job is limited to:

Radiation Oncology
Medical & Radiation Oncology
Cancer Service Line
Other

Managerial/Administrative responsibilities within Radiation Oncology for the following:

Capital Budget Total Partial None
Operating Budget Total Partial None
Personnel Budget Total Partial None

I am actively engaged in a service area of education: Yes No

Membership Categories*

Active Membership: Active Members shall be currenlty engaged in administration responsibilities of radiation oncology at the executive, divisional or department level, on a full-time basis. Functions should include a spectrum of responsibilities in (1) personnel: techical, clerical and ancillary employees; (2) budgetary responsibilities in a t least two of the following areas: personnel, operating expense, capital equipment; and (3) development of operational proceures and guidelines for radiation oncology department.

Contributing Membership: Contributing Members shall be those persons who are ineligible for Active membership, but wish to contibute toward the goals of the Society. Contributing members may include consulting and commercial firms having products directly relating to radiation oncology. Contributing members shall have all the privileges of membership extended by the Society except those of making motions, voting, serving on committees and holding office.

Membership for which you are applying: Active Contributing

All applications are reviewed and endorsed by the Membership Committee. Annual membership dues are established by the Board of Directors and are subject to change. Current annual dues for Active membership are $200 and for Contributing membership is $275.

Payment Information*

Total Due	$
Credit Card Type:
Credit Card Number:
Expiration Date	/
Card Holder Name:
Security Code:
Billing Address:
Billing Address Line 2:
City:
State:
Zip:

Please upload either your Institutional Job Description or Departmental Performance Evaluation (.pdf or .doc format only)*

If mailing, send completed application, check and attachments to:
SROA
5272 River Road, Suite 630
Bethesda, MD USA 20846
Fax: 301-656-0989

SROA APPLICATION FOR MEMBERSHIP

NAME

PERSONAL INFORMATION

CURRENT POSITION

Professional Work/Education History *

Membership Categories*

Payment Information*