Membership App

 

WISCONSIN CANCER REGISTRARS’ ASSOCIATION       

NAME: ________________________________________________________________

TITLE:_________________________________________________________________

EMPLOYER: ___________________________________________________________

EMPLOYER’S ADDRESS: ________________________________________________

CITY: ______________________________ STATE:  _____            ZIP CODE: _______

BUSINESS PHONE:   (_______)________-_______________          EXT. ____________

BUSINESS FAX:  (_______)__________-________________            VENDOR: ________

WORK DAYS: ___________________________________ HOURS: __________

E-MAIL ADDRESS: ______________________________________________________ 

HOME ADDRESS: _______________________________________________________
 
CITY: _______________________________           STATE: _____    ZIP CODE: _____ 

HOME PHONE:  (________)__________-_______________________________________ 

PREFERRED MAILING ADDRESS:     (circle one)                  BUSINESS                  HOME
 
CREDENTIALS:    (circle all that apply)     CTR        RHIT        RHIA       LPN         RN         OTHER              
 
MEMBERSHIP CATEGORY:   (circle one)

Before 12/31/10    ACTIVE ($20.00)        ASSOCIATE ($25.00)

After  12/31/10      ACTIVE ($25.00)       ASSOCIATE ($30.00)
 
Active:                   An active member is directly involved with any or all facets of Cancer Registry work; that is, one who works directly with the operation, function or supervision of Cancer Registry.

Associate:             An associate member is one who is not directly involved with Cancer Registry work itself, but has an interest in Cancer Registry work or in the field of oncology.

 SIGNATURE: _________________________________       DATE: _________________ 

 

Please make your check payable to WCRA. Dues must be paid by December 31st.

Return to:

Nancy Sonnleitner

291 Graceland Drive

Oshkosh, WI 54904

Email:  nsonnlei@affinityhealth.org