NSRT Officer Nomination

The Nebraska Society of Radiologic Technologists

An Affiliate of the American Society of Radiologic Technologists
NSRT Officer Nomination

All nomination forms must be received 2 hours prior to the final business to be elgible for election.
Please upload a picture of yourself. jpg and png formats are preferred.

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Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please select the Office that you are seeking
Date of ARRT Certification
Date of Membership in NSRT
Date of Membership in ASRT
Graduation Date
Educational Program Attended
Current Employer
Present Position
Previous Experience (where, how long)
Specialized Education Received
Past NSRT Office/Committees Held
Briefly explain why you are running for this office.
If I am unable to be in attendance at the time of election / installation, I do hereby agree to accept the office and its responsibilities, if elected.
Date
Enter today's date
Signature
P.O. Box 6103, Lincoln, NE 68506 | Phone: 402-405-4830 | nsrtofc@gmail.com
Should be Empty:

The Nebraska Society of Radiologic Technologists