TSRT 2011 On-Line Pre-registration Form

Texas Society of Radiologic Technologists, Inc. (TSRT)

Donation Form

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Thanks so much for supporting TSRT - the largest association in Texas for Radiologic Science Professionals.

Please complete this form online to make a donation. Please indicate whether this is a memorial or an honorarium. May TSRT send the individual or their family an acknowledgement to recognize your gift? Is this an unrestricted donation or designated for a specific event?

Last Name
First Name
Address
City
State
Zip Code
Day Phone
Evening Phone
Email
Professional Credintal Status
Donation Amount
Credit Card Payment Options	Visa
	MasterCard
	Discover
Card Number
Expiration Date
Security Code Digits
Name on Credit Card
Is this a Memorial or Honorarium?	Memorial
Is this a Memorial or Honorarium?	Honorarium
Acknowledgement Mail To:
Address
City
State
Zip Code
Is this a targeted donation?	Annual Meeting Events
	CERTT Program
	Awards & Recognition
	Equipment Purchases
	Website
	Unrestricted

Click Submit when complete.

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