MEMBERSHIP APPLICATION

If you would like to apply and make payment with a credit card
(Visa, MasterCard, American Express) please complete this application and
continue to the secure payment page.

If you would prefer to mail in your application along with a check,
complete the pdf format file: membership.pdf (requires Adobe Acrobat Reader)
and return along with your membership fee to:
SAWI, P.O. Box 885, Schererville, IN 46375.

Practicing Radiologists: $100.00 per year
Residents or Fellows: Free. Just fill out the application.

Name
Salutation:
First Name:
MI:
Last Name:
Degree:

SAWI Information
Member ID:
Password:
Verify Password:

Institutional Address (Will appear in Membership Directory)
Institution:
Department/Room:
Street:
City:
State:
Zip:
Country:
Office Phone:
Office Email:
Fax:

Home Address (Will not be published)
Street:
City:
State:
Zip:
Country:
Home Phone:
Mobile Phone:
Secondary Email:
Spouse's Name:

Background
Medical School:
Year Graduated: (YYYY)
Residency Institution:  
Residency Type:
Year Graduated: (YYYY)
Fellowship Institution:
Fellowship Type:
Year Graduated: (YYYY)
Year of Board Certificate: (YYYY)

Current Information
Do you practice at an institution with a residency program? Yes No
Do you practice at an institution with a fellowship program in women's imaging? Yes No
Member Comments: