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) Three-year Renewal fee of $300.00 is due on or before Nov 15, 2024

Do Not Send CME Certificates or Transcripts!
MRI CME Statement Must Be Signed On The Renewal Form!

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

If YES, submit details for review.

Please complete the sentence:

*Renewal is mandatory to maintain your Credential & Certification Registry Active status.
**The MRI CME Statement must be Signed & Returned to receive your Certificate & ID Card.
***Late Fees Apply / Failure to Renew Will Lead to Revocation (see note) after Nov 15, 2024.
****Not Tax Deductible.
***** Consult your Tax Advisor for Tax Deductibility.

Note: Revocation renders your Credential & Certification null & void requiring completion of an application and sitting for the examination. No exceptions!