(Please print, complete and mail along with the membership fee to the address at the bottom.)
Last name_________________________First Name_________________MI_______Credentials____
Job Title__________________________________________________Birth Month/Day__________
Employer_____________________________________________________________
Address______________________________________________________________
City/State/Zip__________________________________________________________
Work phone (____)_____________ Fax(____)_____________ Home Phone (____)_____________
Can we publish your home phone number in the membership roster? ______yes _______no
Preferred mailing location _______Business (use above address) ______Home (use address below)
Home Address__________________________________City/State/Zip_______________________
What facet(s) of cancer data or registry work does your job duties include?
Administration/supervision of cancer program ______ Registry Management ______ Abstracting _____
Follow-up _____ Other______________________________________________________________
Are you currently a member of National Cancer Registrars' Association? ______yes ______no
Have you ever been a member of GATRA? ______yes ______no
If yes, reason you left GATRA_________________________________________________________
Educational Background_____________________________________________________________
________________________________________________________________________________
Relevant Work History______________________________________________________________
________________________________________________________________________________
I hereby apply for membership in GATRA.
Signature_____________________________________ Date______________________
We are pleased that you have decided to become a member of GATRA. Benefits of membership include our quarterly newsletter, reduced registration fees for educational meetings, GATRA membership pin, CTR pin for members that pas the national certification exam, educational materials, leadership and networking opportunities. To get involved with GATRA, consider working on a committee, submitting an article to the newsletter or run for office. Your suggestions, ideas and comments are always welcome.
Annual dues are $35 for first year; $20 annually. Dues are billed in November of each year and are considered delinquent after January 1. A reinstatement fee of $10 is charged for late payment.
Please make all checks payable to GATRA.
Send completed application and payment to: Mary Lewis, ART, CTR, 592 Linda Lane, Powder Springs, GA 30127. If you have any questions, please call Mary at (404) 727-9787.