Annual membership is $40.00 per person. $5 of this amount is put into a licensure fund designed to provide
ISETT with the necessary monetary resources to lobby at the state level about issues that may adversely
affect the field of END. You may donate additional amounts to be put in either the general fund or the
licensure fund by checking the box at the bottom of this form. These donations are tax deductible. If you have
questions regarding ISETT membership please visit our website at www.isetthome.org or call (317) 338-3004
and ask for an ISETT representative.
Name: ________________________________________________________________
Last, First, M.I.
Home address: _________________________________________________________
City, State, ZIP: _________________________________________________________
Employer: _____________________________________________________________
Work Phone: _________________________ Home Phone: _______________________
Email address: __________________________
Information may be published in the ISETT directory: YES / NO
Credentials: R. EEG T. R. EP T. CNIM R. PSG T. R. NCS T.
R.N. M.D. Other Credentials or Education:
Special Areas of Interest: EEG EP Video NCS IOM PSG
Renewing or New Member? _____________ Referred by: __________________________
Additional Donation Amount: $_______
_____________________________________ _____________________
Signature Date
Make sure to sign and date your application. Enclose this form and dues (check made out to “ISETT”) in
envelope and mail to:
ISETT with the necessary monetary resources to lobby at the state level about issues that may adversely
affect the field of END. You may donate additional amounts to be put in either the general fund or the
licensure fund by checking the box at the bottom of this form. These donations are tax deductible. If you have
questions regarding ISETT membership please visit our website at www.isetthome.org or call (317) 338-3004
and ask for an ISETT representative.
Name: ________________________________________________________________
Last, First, M.I.
Home address: _________________________________________________________
City, State, ZIP: _________________________________________________________
Employer: _____________________________________________________________
Work Phone: _________________________ Home Phone: _______________________
Email address: __________________________
Information may be published in the ISETT directory: YES / NO
Credentials: R. EEG T. R. EP T. CNIM R. PSG T. R. NCS T.
R.N. M.D. Other Credentials or Education:
Special Areas of Interest: EEG EP Video NCS IOM PSG
Renewing or New Member? _____________ Referred by: __________________________
Additional Donation Amount: $_______
_____________________________________ _____________________
Signature Date
Make sure to sign and date your application. Enclose this form and dues (check made out to “ISETT”) in
envelope and mail to:
ISETT Membership Application
Marti Sherrill ISETT Treasurer 6825 Silver Tree Drive Indianapolis, IN 46236 |