N.C.B.A. Membership Application

Type of Application being applied for:

Individual         __   $50.00
Associate          __   $25.00
Student            __    $8.00
Corporate          __  $400.00
Institution        __  $100.00
  [Half-price after July 1st]


Mail Application and payment to:
North Carolina Biomedical Association
7474 Creedmoor Road, PMB 196
Raleigh, NC 27613-1665
Ph: 919-688-6890

[Please type or print all information]

Name	______________________________________________________________________________________

Mailing Address: ___________________________________________________________________________

   City:  _____________________________________    State:  _________    Zip: _______________

   E-Mail:  ________________________________________________________________________________

Employer:	________________________________________________________________________________
             
Facility: (If different from above)_________________________________________________________
             
Address:  ___________________________________________________________________________
                  
City:  _____________________________________     State:  _________     Zip:  ______________
                
Phone:  ________________________________    FAX:  ___________________________________

Position or Title  _________________________________     Department	_____________________________

Immediate Supervisor & Title	________________________________________________________________


Describe in full your job functions & responsibilities:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

References - Please List three health care professionals who have knowledge of your work experience:

Name	Address	Phone No.	Position

A. ______________________________________________________________________________

B. ______________________________________________________________________________

C. ______________________________________________________________________________

Complete only those items in this section necessary to establish compliance with the criteria for the appropriate membership category.

Are you a certified BMET?    Yes  __     No  __      

Type Certification 	_______________________________

If Yes, list certifying organization ________________________________________    

Date	________________

If you are a member of other professional organizations, please list

_________________________________________________________________________________________

_________________________________________________________________________________________

Education

Name	Course/Program	Degree 	Dates	

A. ______________________________________________________________________________

B. ______________________________________________________________________________

C. ______________________________________________________________________________

Practical Experience

Employer	Position/Title	Dates

A. ______________________________________________________________________________

B. ______________________________________________________________________________

C. ______________________________________________________________________________

Use additional paper or attachments as needed

Membership Categories

Individual - Those persons whose prime responsibility lies in the selection, operation, repair and 
support of biomedical instrumentation in health care facilities. They shall have:

* At least an Associate Degree in Biomedical Engineering Technology, 
  or equivalent military experience, or

* At least an Associate Degree in Electronics Engineering and one [1] 
  year of experience in the support of biomedical instrumentation 
  in health care facilities, or

* At least three [3] years experience in the support of biomedical
  instrumentation in health care facilities, or

* At least a Certification of Completion from the North Carolina Department
  of Labor, Apprenticeship Division as approved by the NCBA Apprenticeship Committee, or

* Employment as Faculty, Professional Staff and/or Administration in education 
  or health care institutions furthering knowledge in disciplines pertinent to the NCBA

Associate - Those persons employed by an institution, corporation or other organization
involved in the health care field who do not meet the requirements for an individual
membership shall be eligible for associate membership. The associate member shall have no vote.

Student - Those persons studying the disciplines pertinent to the NCBA.
The student member shall have no vote.

Corporate - Those companies or business organizations which manufacture, sell,
service or otherwise support medical instrumentation or facilities. Corporate 
members shall have no vote.

Institution - Those institutes which aid in the support of the NCBA and/or it's 
membership. These memberships shall be assigned categories or membership according 
to the applicant's qualifications. The institution as such shall have no vote.