Society for Imaging Informatics in Medicine by nwr19852

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									                            Society for Imaging Informatics in Medicine
                            Institutional Membership Application
Institution:                                                                       SIIM Membership

Name: ____________________________________________           The institutional membership focuses on bringing together a
                                                             team of professionals from the same institution into SIIM (i.e.
Address: __________________________________________          physician, healthcare administrator, physicist, IT, PACS
                                                             Administrator, etc.) who as a group are exploring and applying
City:______________________________________________          advanced technology information systems to improve the
                                                             delivery of medical imaging services. The resources of SIIM
State: ____________________________________________          are applied to help educate individuals sponsored by their
                                                             institutions of PACS, and image management technology
Zip: ______________________________________________          through publications, meetings, seminars, and personal
                                                             communications. The institutional membership plan is also
Country: __________________________________________          intended to foster a continuing joint effort between SIIM
                                                             institutional and corporate members to explore and address
Phone: ____________________________________________          issues involving PACS and IS integration through education
                                                             and shared experience.
Fax: ______________________________________________
                                                                             SIIM Membership Category
Website: __________________________________________                             (Indicate selection below)

Primary Contact:                                                  US/Canadian Institutional Membership $600.00 –
                                                             US/Canadian membership is available to institutions involved
                                                             in the medical imaging field and which are located in the US or
Salutation:        Dr.      Mr.    Ms.
                                                             Canada.
First Name: ________________________________________              International Institutional Membership $800.00 –
                                                             International membership is available to institutions involved
Middle Name: ______________________________________          in the medical imaging field and which are located outside of
                                                             the US or Canada.
Last Name: ________________________________________
                                                                                 Membership Benefits
Degree: ________________           Male    Female
                                                             •   Four SIIM annual memberships for employees. SIIM
Title: _____________________________________________             members will receive the Journal of Digital Imaging (JDI)
                                                                 published quarterly, and SIIM News.
Department: _______________________________________
                                                             •   Complimentary copy of the SIIM University Syllabus
Organization:_______________________________________         •   Discounts on meeting registration fees and SIIM
                                                                 publications (with volume discounts for additional copies).
Address: __________________________________________          •   Special consideration given to institutional members in the
                                                                 site selection process for hosting the annual meeting of the
City/State/Zip: _____________________________________            Society for Imaging Informatics in Medicine.

Country: __________________________________________
                                                             •   Special consideration when applying for SIIM informatics
                                                                 grants.
Phone: ____________________________________________          •   50% reduction in participation fees in the IRISS, FUSUN, &
                                                                 SUMMIT user groups that exchanges innovation solutions to
Fax: ______________________________________________              application problems.
                                                             •   Invited participation in the SIIM Vendor/Provider
Email: ____________________________________________              Partnership Program.
                                                             •   Receive consultation on individual needs from experienced
                                                                 SIIM members through the expert hotline.
                  Payment Information
                                                             •   Inclusion on SIIM website institutional member listing with
Signature: _________________________________________             link back to institution's web site.

Date: _____________________________________________
                                                             •   10% discount on classified advertising in SIIM News.
                                                             •   Complimentary SIIM membership labels for educational
Payment Options:      VISA         MasterCard                    programs
              American Express     Discover Card
              Check enclosed                                                   Submission Instructions
              $0.00
Total Paid: $____________
                                                             Please return your: (1) completed application form and
Credit Card Number: _________________________________        (2) payment to:

Expiration Date (MM/YY): _____________________________            Society for Imaging Informatics in Medicine
                                                                  19440 Golf Vista Plaza, Suite 330
Name on credit card:_________________________________             Leesburg, VA 20176
Zip Code of Credit Card billing address                           Phone         703-723-0432
(for confirmation of US cards only): _____________________        Fax:          703-723-0415
                                                                  Email:        info@siimweb.org
Security Code (from back of card): ______________________         Web:          www.siimweb.org
                                     Society for Imaging Informatics in Medicine
                                     Institutional Membership Application

Sponsored Member #1                                                             Sponsored Member #2
Salutation:               Dr.        Mr.       Ms.                              Salutation:               Dr.        Mr.       Ms.

First Name: ________________________________________                            First Name: ________________________________________

Middle Name: ______________________________________                             Middle Name: _______________________________________

Last Name: ________________________________________                             Last Name:_________________________________________

Degree: ______________                        Male                   Female     Degree: _____________                         Male                   Female

Title: _____________________________________________                            Title:______________________________________________

Department: _______________________________________                             Department: _______________________________________

Organization:_______________________________________                            Organization: _______________________________________

Address: __________________________________________                             Address:___________________________________________

City/State/Zip: _____________________________________                           City/State/Zip: ______________________________________

Country: __________________________________________                             Country:___________________________________________

Above Address is:                          Work               Home              Above Address is:                          Work               Home

Phone: ____________________________________________                             Phone: _____________________________________________

Fax: ______________________________________________                             Fax: _______________________________________________

Email: ____________________________________________                             Email:______________________________________________

Occupation                                 Specialty                            Occupation                                 Specialty
(select one category – best match)         (select one category – best match)   (select one category – best match)         (select one category – best match)

   Physician                                  Radiology                            Physician                                  Radiology
   Medical Physicist                          Cardiology                           Medical Physicist                          Cardiology
   Technologist                               Nuclear Medicine                     Technologist                               Nuclear Medicine
   Healthcare Administrator                   Oncology                             Healthcare Administrator                   Oncology
   PACS Administrator                         Information Systems                  PACS Administrator                         Information Systems
   Health Info Professional                                                        Health Info Professional
   Scientist/Researcher                       Other _______________                Scientist/Researcher                       Other _______________
   Computer Scientist                                                              Computer Scientist
   Engineer                                                                        Engineer
   Educator                                                                        Educator
   Vendor/Consultant                                                               Vendor/Consultant
   Student/Resident                                                                Student/Resident
                                     Society for Imaging Informatics in Medicine
                                     Institutional Membership Application

Sponsored Member #3                                                             Sponsored Member #4
Salutation:               Dr.        Mr.       Ms.                              Salutation:               Dr.        Mr.       Ms.

First Name: ________________________________________                            First Name: ________________________________________

Middle Name: ______________________________________                             Middle Name: _______________________________________

Last Name: ________________________________________                             Last Name:_________________________________________

Degree: ______________                        Male                   Female     Degree: _____________                         Male                   Female

Title: _____________________________________________                            Title:______________________________________________

Department: _______________________________________                             Department: _______________________________________

Organization:_______________________________________                            Organization: _______________________________________

Address: __________________________________________                             Address:___________________________________________

City/State/Zip: _____________________________________                           City/State/Zip: ______________________________________

Country: __________________________________________                             Country:___________________________________________

Above Address is:                          Work               Home              Above Address is:                          Work               Home

Phone: ____________________________________________                             Phone: _____________________________________________

Fax: ______________________________________________                             Fax: _______________________________________________

Email: ____________________________________________                             Email:______________________________________________

Occupation                                 Specialty                            Occupation                                 Specialty
(select one category – best match)         (select one category – best match)   (select one category – best match)         (select one category – best match)

   Physician                                  Radiology                            Physician                                  Radiology
   Medical Physicist                          Cardiology                           Medical Physicist                          Cardiology
   Technologist                               Nuclear Medicine                     Technologist                               Nuclear Medicine
   Healthcare Administrator                   Oncology                             Healthcare Administrator                   Oncology
   PACS Administrator                         Information Systems                  PACS Administrator                         Information Systems
   Health Info Professional                                                        Health Info Professional
   Scientist/Researcher                       Other _______________                Scientist/Researcher                       Other _______________
   Computer Scientist                                                              Computer Scientist
   Engineer                                                                        Engineer
   Educator                                                                        Educator
   Vendor/Consultant                                                               Vendor/Consultant
   Student/Resident                                                                Student/Resident

								
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