This on-line membership application for is intended for physicians and allied health personnel only. Parties interested in corporate membership are referred to the corporate membership application form for further details. Additional information may also be obtained by contacting MIRS directly by e-mail (info@mirs.org) or via our feedback connection.

Please fill out this application completely. Avoid using the "Enter" key to navigate the form as this may result in a premature "submit form" event on some browsers. If you encounter difficulty in submitting this application via the Internet, the form may be printed and submitted by mail with the appropriate fee to the address below.

Following review and approval of your on-line application, you will receive an initiation fee statement via e-mail. The initiation fees and subsequent annual dues are: $150 for physicians; $60 for allied health workers.

Physician members in active practice will be included in the MIRS physician listings. A physician's profile page will be prepared and uploaded at no charge for M.D. and D.O. members submitting the necessary information.

Postal address:

Application for Membership

1) Please tell us about yourself

Your full name

E-Mail

Profession

MD DO RT RN other   

Hospital affiliation

Mailing address

Mailing address (con't)

City

State / ZIP

Business phone

FAX

Home Phone

Please do not put me on the MIRS e-mail list (Members On-Line)


2) Complete this section only if applying for professional membership (DO or MD)

Medical School

Radiology Residency

VIR Fellowship


3) Where did you hear about MIRS

  • Please check all that apply
    MIRS Mailings (Meeting Brochures)
    From a Vendor's Representative
    From a Colleague
    On the Internet
    Other (please specify):

  • Have you attended any MIRS Conferences in the past?
    Yes No

4) Please tell us about your use of the World Wide Web

  • What browser do you usually use when working on the Web?
  • Is your primary Internet/Web connection:
    At work At home Other (please specify):
  • How much time per week do you spend on the Web?
  • The above time is spent (please check all that apply):
    Looking for information of professional interest
    Looking for information on commercial products/services
    Academic research
    Investment management and/or research
    Browsing for entertainment purposes
    Interacting with other people on the Internet (newsgroups, chat, etc.)