Affiliate Delegate Information Form

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* 1. First and Last Name

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* 2. ASRT ID number

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* 3. Affiliate Name

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* 4. Please upload a signed and dated employment letter showing current proof of practice in the medical imaging and radiation therapy profession or health care. The date of the letter cannot precede the date of the Affiliate Delegate Submission Form.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 5. Please upload your current affiliate card. Please note that per ASRT bylaws: A delegate shall be a voting member of the ASRT for two years immediately preceding nomination and a current member of the affiliate.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 6. If not listed in your ASRT account, please list at least one of your affiliate activities as stated in the ASRT bylaws:
A delegate shall have served as an officer, or on the Board of Directors or as a committee member in the affiliate being represented.

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* 7. By typing your name, please attest that you have read the ASRT bylaws:

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* 8. By typing your name, please attest that your employer is aware of the of the obligations and time commitments needed to fill this position, including attendance to the ASRT Annual Governance and House of Delegates Meeting in June.