Instructions
RED BLUE
1. Member Information
Prefix:
Ms.
Mr.
Dr.
First Name:
Middle Intial:
Last Name:
Suffix (II, III, Jr, Sr, etc):
Credentials:
If you plan to use your work address as your preferred mailing address, please complete this information:
Organization:
Department :
Mailing Address:
Mailing Address:
City:
State/Province:
Zip+4/Postal Code:
Country Code (if not US):
Daytime Phone (US/Canada only):
Ext:
Email:
For identity verification and CME tracking purposes, please provide the following:
Birthdate (MM/DD/YYYY) :
Social Security #
XXX-XX-(last 4 digits only)
Gender:
2. Specialties Practicing and Registrations/Certificates
A. Currently Practicing
B. Registrations/Certificates you hold:
C. Registry Numbers (if applicable)
D. If ARDMS/CCI Registered,
E. Education: Highest Diploma/Degree
3. Membership Dues
4. Where did you hear about SDMS?
I heard about SDMS from:
If you received an SDMS membership application, enter the source code (located near bottom right or top right corner)
Source Code:
5. Donations
The SDMS Educational Foundation supports ultrasound education and research. 100% of contributions are tax deductible as charitable contributions.
SDMS Educational Foundation: $
The SDMS Legislative Fund helps support the SDMS' expanding lobbying activities to help protect sonographers' careers and interests. Contributions are not tax deductible.
SDMS Legislative & Regulatory Fund: $
6. Payment
Credit Card Type:
Select Card Type
American Express
Discover
Mastercard
Visa
Credit Card #:
3 or 4-digit Card Security Code:
Expiration Date (MMYY):
MM
1
2
3
4
5
6
7
8
9
10
11
12
YY
08
09
10
11
12
13
14
15
16
Name on Card:
Card Billing Address:
City:
State/Province:
Zip+4/Postal Code:
Country Code (if not US):
