NEW JERSEY EDUCATORS IN

							                              MEMBERSHIP APPLICATION/RENEWAL FORM
                                    (Membership year Sept - Aug.)

Applicants Name_____________________________________________________

E-Mail Address______________________________________________________
                                     (If not provided, the member will not receive mailings)
Home Address_______________________________________________________

                        _______________________________________________________

Home Telephone: (____)____-_______Cell Phone (optional) (____)____-________

Employer’s Name_____________________________________________________
Work #       (____)_____________________________________________________
Position/Title:_______________________________________________________

STATUS: Check the appropriate space

FEES: Active - $25.00                Associate - $30.00


           Active: Technologists currently engaged in the teaching of radiologic technology on a full
            or part time basis or Radiologic Technologists who by their duties &
           responsibilities are directly involved in the education of radiologic technologists.
           Associate: Those persons not eligible for Active Membership but who have
contributed            to the aims & purposes of the organization.

Signature___________________________________________________________

           ****PLEASE MAKE ALL CHECKS PAYABLE TO NJERI****

Return completed Application & Associated Fees To:
                                           Sue Pyner-Moss
                                       354 Rolling Rock Road
                                       Mountainside, NJ 07092



(TAX ID# 22-3617222)