Application for membership to the NLAMRT

First Name :
Last Name :
Initial :
Gender :
 Male    Female  
Mailing Address :
Landline Number :
Mobile Number :
E-mail :*
Date of Birth :
Are you a Canadian citizen?
 Yes    No

If no, please provide documentation to support ability to work in Canada.

In which discipline are you applying for membership?
 Radiation Technology   

 Nuclear Medicine Technology    

 Radiation Therapy    

 Magnetic Resonance Imaging   
Are you currently employed as a Medical Radiation Technologist (MRT)?
  Yes    No

If yes, please complete the following section:

Central Health Site :
Eastern Health Site :
Labrador-Grenfell Health Site :
Western Health Site :
Employer Address :
Employer Phone Number :

Education History

Did you graduate from an accredited education program?
 Yes    No
Did you write and successfully pass the CAMRT National Certification Exam?
 Yes    No
What year did you write the exam?
Name of Educational Institution

*Note: You must please provide documentation of national CAMRT certification and educational transcripts upon applying for membership*

Security Code : *