STC-HPS Bulk Membership Application Form

STC-HPS Membership Application

State of Texas Chapter of the Health Physics Society
Use this form to bulk register Professionals

Our membership rates are good for each calendar year regardless of when the membership is paid for and will be due for renewal on 12/31 of the year in which it was paid.

This Registration Period is from 12/31/2024 through 12/30/2025.
Submitter's Name*

First NameLast Name
Email Address*
example@example.com
Professional $40

Benefits include:
- Job postings
- Discounted Conference registration fees
- Notice of conferences
- Invite to STC HPS Breakfast at HPS National
- and more

Register Professional #1?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #2?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #3?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #4?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #5?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #6?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization name

Register Professional #7?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Business/Organization Name

Register Professional #8?
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Business/Organization Name

Register Professional #9?
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Business/Organization Name

Register Professional #10?
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Business/Organization Name

Payment by credit card or PayPal
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Professional Registration
$20.00 Quantity

Total

$0.00

Payment Methods

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