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MEMBERSHIP FORM

Date :
Surname :
Name :
Middle Name :
Birthdate :
Sex :
Office Address :
Office No. :
Fax No. :
Home Phone No. :
Mobile No. :

Medical School :
Year Graduated :
Title of Certificate of Ultrasound Training :
Ultrasound Training Institute/ Hospital :
Specialty Training (for fellows) Date & Duration of Training/Specialty :
Office Address (Site of Ultrasound Practice) :
Duration of Medical Practice (Including Residency & Fellowship) :
Duration of Clinical Ultrasound Practice :

Number of Patients Examined at time of Application (pls. check)
20 50 170 300 500 1000

ULTRASOUND PRACTICE LIMITED TO: (You may check more than one)

A. OB
B. Gyn
C. OB-GYN


D. OB-GYN with     Doppler Studies
      1. Pediatrics
      2. Adults
      3. Both
E. Cardiology
      1. Pediatrics
      2. Adults
      3. Both		 F. Abdomen
      1. Gastro-Intestinal           (Hepatobiliary)
      2. Gastro-Intestinal           (Hepatobiliary)

G. Neurosonology
      1. Cranial
      2. Spine
      3. Muscle
      4. with Doppler                Studies

 H. Soft Tissue
      1. Thyroid
      2. Breast
      3. Musculo-                Skeletal

PRC No.
 Year Licensed
Specialty
 Society Affiliation
Reference Persons (PSUCMI Member/FPIP Member/PMA) Others

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2.
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