ISMRM

Print Form

Application for FULL Membership

Please send application and all materials to ISMRM: P.O. Box 45690 San Francisco, CA 94145-0690, USA Phone: +1 510 841 1899 Fax: +1 510 841 2340 E-mail: ismrm.full@ismrm.org Web site: www.ismrm.org

Name: Family Name First/Given Name Middle Name

Honoric:
(Required)

Gender: (Required) p Male p Female Date of Birth: (Required)

How did you become aware of ISMRM membership? p Through an associate p Saw ad in journal p Attended annual meeting p Received brochure/postcard in mail

Date of Degree
(Required)

Professional Classication:
(Required)

Primary eld of endeavor: BasiC SCieNCe CliNiCaL SCieNCe p Biochemistry p Biophysics p Chemistry p Drug Development p Engineering p Mathematics p Molecular Imaging p Oncology p Cardiology p Internal Medicine p Molecular Imaging p Neurology p Oncology p Psychiatry p Radiology p Surgery p Other:

p Undergraduate Degree p M.Sc. p M.D. Candidate p M.D. p Ph.D. Candidate p Ph.D. p Professor p Other:

p Basic Scientist p Clinical Scientist p Educator p Industrial Management p Radiologist p Radiology Support Personnel p Other:

ISMRM makes its member list available to a few carefully screened companies. If you DO NOT wish to be included, check here:

FOR OFFICE USE ONLY

Date Received:_______________ Member ID:__________________ CV Received: p Yes p No Sponsor ID:____________________

p Physics p Physiology p Other:

Send annual renewal notice to my: p Institution p Home Send journals and correspondence to my: p Institution p Home

CONTACT INFORMATION

PLEASE PROVIDE BOTH YOUR INSTITUTION AND HOME CONTACT INFORMATION

Institution Name Street Address: City & State/Province: Country & Postal Code: Telephone: Fax: Primary Email (Required): Street Address: City & State/Province: Country & Postal Code: Telephone: Fax: Email: Home Contact Information

STUDY GROUPS ($20.00 each for Full Members)

STUDY GROUPS

p Cardiac MR p Current Issues in Brain Function p Detection & Correction of Motion in

MRI & MRS

p Electro-Magnetic Tissue Properties p High Field Systems & Applications p Hyperpolarized Media MR p Interventional MR p Molecular & Cellular Imaging

p MR Engineering p MR Flow & Motion Quantitation p MR in Drug Research p MR of Cancer p MR Safety

p Musculoskeletal MR p Perfusion p Psychiatric MR Spectroscopy &

Imaging

p Diffusion p Dynamic NMR Spectroscopy

p White Matter

MEMBERSHIP DUES

2014 MEMBERSHIP DUES Membership is effective from 1 January31 December of the year the application is approved. Dues remittance must accompany the membership application submission. All applications received after 1 October will be applied to the following year.

Calculate your membership fees here. All fees must be in US dollars. Study group dues: Number of study groups x US $20.00 = US$

p Full Member with one electronic journal

Please choose one:

p JMRI or p MRM

US $245 US $295 US $405 US $615

p Full Member with both electronic journals (JMRI and MRM) p Full Member with one print journal Please choose one: p JMRI or p MRM p Full Member with both print journals (JMRI and MRM)
Card holders Name:

I would like to make a donation to the ISMRM Research & Education Fund. (See other side.) US$ 2014 Membership dues: US$ Total amount enclosed (Required): US$

If paying by check, make payable to ISMRM. To pay by credit card, please check card type and complete below: p Visa p MasterCard p AMEX p Discover Expiration Date: (Required) Billing Zip/Postal Code: (Required)

PAYMENT

Credit Card Number: (Required) Cardholder Signature: (Required) Billing Address

SIGNATURES

Applicant Signature:

Date:

ISMRM FULL-MEMBER AppliCaNTs MUST SUBMIT:

Sponsor Signature: Sponsor Name (please print): p I do not know a Full Member of the Society

p Membership dues p Completed application p One (1) copy of current CV p Application with sponsor signature

CULTIVATE THE MR LEADERS OF TOMORROW

THE ISMRM RESEARCH & EDUCATION FUND

Our Mission & Objective:

THE ISMRM Research & Education Fund was established to support the next generation of specialists in the field of magnetic resonance.

RESEARCH & EDUCATION FUND

ISMRM.ORG/FUND/

By assisting scientists and clinicians alike, the fund ensures that new trainees will have equal opportunity to benefit from association with the ISMRM, regardless of scientific discipline, geography, country of origin and resources available.

HOW THE FUND WORKS:

The Research & Education Fund will support:  Seed grants for trainees and junior faculty to stimulate original research and development in the field of magnetic resonance;  Trainee stipends for attendance at ISMRM organized annual meetings and workshops; and  Board mandated programs that adhere to and advance the mission and objectives of the Fund.

TO MAKE A DONATION OR LEARN MORE, PLEASE VISIT WWW.ismrm.orG/Fund/

YOUR REWARDS

A  cknowledgment on the ISMRM website and at the annual meeting; A  ccess to the Donor Lounge at the annual meeting*; and T  he satisfaction that you play a significant role in securing the future of programs that have assisted over 1000 trainees, including fellows and residents, annually.
* Dependent upon donation level