Tech's Name:

Tech's ARMRIT Certificate number:

Email:

Address

City

State

Zip

Phone

Work Phone

Employer

City

State

Equipment Experience

Include the following:
1) Two-year Renewal fee of $350.00 is due on or before March 15, 2012.

2) Evidence of at least twelve (12) CME credits in MRI Technology for 2010 & 2011.

3) Do not delay payment. CME evidence is due by December 31, 2012.

4) CME credits are not required by Techs that passed the exam in 2009, 2010, 2011.

Proof of CME (12) credits: (choose one):

Passed Exam in 2009,'10,'11:
Already on file:
Will send by 12/31/11:

Were you convicted of a felony or misdemeanor since last renewal?  YES    NO

If YES, submit details for review.

Please complete the sentence:

Renewal Fee: 350.00, (300.00 plus 50.00 late fee)