NSRT Life Member Nominee Form

The Nebraska Society of Radiologic Technologists

An Affiliate of the American Society of Radiologic Technologists
NSRT Life Membership Nomination Form

NOMINATION DEADLINE: OCTOBER 1
Name of Nominee

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name of Nominator

First NameLast Name
Nominator Email
example@example.com
Nominator Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nominator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
The life member category is an honor recognizing individual members for their special contributions to the NSRT and the profession. This membership status is limited to active members who have rendered exceptional service and dedication to the NSRT. Life members are exempt from all annual dues payments. Life members retain all rights and privileges of regular active members.

Life members are recognized for their outstanding contributions to the profession and to the NSRT. In particular, this membership category recognizes a wide range of activities, not solely maintaining a long time NSRT Membership. Life members should be recognized for sustained superior performance in support of the NSRT and the radiologic science profession.

They shall be selected by a unanimous vote of the Board of Directors, upon the unanimous recommendation of the Life Member Committee and receive Life Member status at an Annual Conference Awards Ceremony.
Has the nominee's participation as a NSRT member reflected exceptional service and dedication to theNSRT and the profession?
Has the nominee been an active NSRT member for at least 10 years as of the date of nomination?
Is the nominee free of attributes and conduct that would discredit the NSRT?
UPLOAD ALL SUPPORT DOCUMENTS HERE

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Life Member Nomination Required Documentation

1. NOMINEE CURRICULUM VITAE:
Nominee’s curriculum vitae. List the nominee’s work experience including length of service, organizations in which he or she has served and positions held, if not in the curriculum vitae.

2. PUBLISHED MATERIALS:
If the nominee has published materials, provide a copy of the author/contributor page from the publication.

3. DESCRIPTION OF SUPPORT:
A detailed description, separate from the letter of support, of the nominee’s demonstrated leadership that has affected the health care or social history of the state of Nebraska through sustained, lifelong contributions to the profession, education, administration, research, economics or literature. The description should include the nominee’s achievements that have enduring value to NSRT and the profession. The description should reflect the nominee’s exceptional service and dedication to NSRT and the profession.

4. LETTERS OF SUPPORT:
Three letters of support from current NSRT members. One of the letters of support may come from the NSRT member submitting the nomination form.

5. RECOMMENDATIONS:
Personal recommendation letters and input from the Board of Directors will also be strongly considered.

6. MINIMUM POINTS:
Each nominee will be given a point value for each criterium met, according to his/her and other documentation received. A minimum of 60 points must be assessed to be eligible for Life Member status. Please conatct the NSRT office at nsrtofc@gmail.com to request a list of criteria and points.
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The Nebraska Society of Radiologic Technologists

NSRT Life Membership Nomination Form