MEMBERSHIP APPLICATIONFirst Name: M.I.: Last Name: Suffix:

Designations: Birth Date: Gender:

WORK ADDRESS:

Company/Institution:

Department: Title:

Street Address:

City, State, Zip: Country:

Work Email: Work Phone:

HOME ADDRESS:

Street Address:

City, State, Zip: Country:

Personal Email: Phone:

Preferred Mailing Address: q Home q Work Preferred Email Address: q Home q Work

MEMBERSHIP TYPE:Please select your appropriate member type below.q Full Member (International) - $510 $102q Associate Member - $345 $69q Associate Scientific Lab Professional - $179 $36q Affiliate Member - $375 $75q Associate Technologist - $123 $25q Technologist - $108 $22q Scientific Lab Professional - $108 $22q Resident/Fellow-in-Training - Freeq Scientist-in-Training - Freeq Technologist-in-Training - Free

ADDITIONAL MEMBERSHIP OPTIONS:Please select the Councils and/or Centers of Excellence to add to your membership.q Academic Council: $15q Advanced Associate Council: $15q Brain Imaging Council: $15q Cardiovascular Council: $20q Center for Molecular Imaging Innovation & Translation: $15q Computer & Instrumentation Council: $15q Correlative Imaging Council: $20q General Clinical Nuclear Medicine Council: $20q PET Center of Excellence: $15q Pediatric Imaging Council: $20q Radiopharmaceutical Sciences Council: $20q Therapy Center of Excellence $15

I agree to abide by the current bylaws, policies and procedures of the Society and any future revisions thereof. I certify that the information given above is correct to the best of my knowledge.

Signature of Applicant: Date:

PAYMENT INFORMATION q American Express q Mastercard q VISA

Credit Card Number: Expiration Date:

Name as it appears on Card: Verification Code:

Cardholder Signature: Today’s Date:

q Check: Please make check payable to the Society of Nuclear Medicine and Molecular Imaging (in U.S. Dollars)

SNMMI’s membership year runs from October 1 – September 30.

Member Dues: $

Chapter Dues: $

Council/Center Dues: $

Total: $

CHAPTER MEMBERSHIP:Members from corresponding countries receive an 80% discount in membership dues. See page 2 for a complete list of eligible countries.

PRINT PUBLICATION(S):SNMMI publications are now online. If you would like print issues, please opt-in below: Opt-inThe Journal of Nuclear Medicine (JNM) q

JNM Supplement(s) Only q

Journal of Nuclear Medicine Technology (JNMT) q

80% OFF

ELIGIBLE CORRESPONDING COUNTRIES Afghanistan Armenia Bangladesh Benin Bhutan Bolivia Burkina Faso Burundi Cabo Verde Cambodia Cameroon Central African Republic Chad Comoros Congo, Dem. Rep. Congo, Rep. Côte d’Ivoire Djibouti Egypt, Arab Rep. El Salvador Eritrea Ethiopia Gambia Ghana Guatemala Guinea Guinea-Bissau Haiti Honduras India Indonesia Kenya Kiribati Korea, Dem. People’s Rep. Kosovo Kyrgyz Republic Lao PDR Lesotho Liberia Madagascar Malawi Mali Mauritania Micronesia, Fed. Sts. Moldova Mongolia Morocco Mozambique Myanmar Nepal

Nicaragua Niger Nigeria Pakistan Papua New Guinea Philippines Rwanda Samoa São Tomé and Principe Senegal Sierra Leone Solomon Islands Somalia South Sudan Sri Lanka Sudan Swaziland Syrian Arab Republic Tajikistan Tanzania Timor-Leste Togo Tonga Tunisia Uganda Ukraine Uzbekistan Vanuatu Vietnam West Bank and Gaza Yemen, Rep. Zambia Zimbabwe

Join the SNMMI global community! Visit www.snmmi.org/join to join online today.