| Print this form and fax or mail: Fax to: (505) 797-3822 Mail to: 5150 San Francisco RD NE, Albuquerque, NM 87109 |
Last Name: __________________________________
First Name: __________________________________
Middle Initial: __________________________________
Street Address: __________________________________
City: __________________________________
State: __________________________________
Zip Code: __________________________________
Telephone: __________________________________
E-mail: __________________________________
Profession: ___ CT Years Experience: ______ ___ Echocardiography Years Experience: ______ ___ Mammography Years Experience: ______ ___ MRI Years Experience: ______ ___ Nuclear Medicine Years Experience: ______ ___ Radiation Therapy Years Experience: ______ ___ Special Procedures / Cardiac Cath Years Experience: ______ ___ Ultrasonographer Years Experience: ______ ___ Vascular Technologist Years Experience: ______ ___ X-ray Tech Years Experience: ______ Instructions: 1. Please print or type clearly. 2. Complete only those items that apply to your profession.
SPECIALTIES:
____________________________________________________
____________________________________________________
EQUIPMENT:
____________________________________________________
____________________________________________________
PROFESSIONAL LICENSURE:
License #: ____________ State: ____ License #: ____________ State: ____
License #: ____________ State: ____ License #: ____________ State: ____
CERTIFICATIONS:
___ ARRT ___ ARDMS ___ NMTCB ___ CNMT ___ RVT ___ RDCS
Other: __________________________ Other: __________________________
Other: __________________________ Other: __________________________
CHICKEN POX STATEMENT:
___ Yes, I have had chicken pox. ___ No, I have not had chicken pox.
FACILITY/SPECIALTY PREFERENCE:
1st Choice: ______________________________________ 2nd Choice: ______________________________________ 3rd Choice: ______________________________________
Date: _______________________
Phone / Email: _______________________
