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N E W M E M B E R A P P L I C AT I O N

Individual Membership

Check here if you do not want the following information to be included in the online membership directory.

Name: (first, middle, last) __________________________________ Gender: Male Female

How many years have you worked for your current employer? Enter 1 for less than 1 year.

Indicate number of years: __________________________________ Home Mailing Address: ____________________________________ City: ____________________________ State/Province: __________ Zip/Postal Code: __________________ Country: _______________ Phone: __________________________________________________ Fax: ____________________________________________________ My preferred mailing address is (check one) Work Home

E-mail address: ___________________________________________ Title: ___________________________________________________

Please check all your degree(s)/certification(s)/ designations.

AA AB AS ASEE BA BS BSBE BSCE BSEE BMET BSME CBET CCE CLES CRES DDS DSc JD LLB LLD DDL LLM MA MBA MD ME MPH MS MSBE MSEE PE PhB PhD RN ScD VMD

Select Type of Membership

Choose one of these options: Individual Member, U.S. $225 Individual Member, Outside U.S. $285 New Professional Membership $60

(This category is intended for those who have worked in the medical technology field for 5 years or less). New Professional memberships are limited to a period of five years.

Student Membership $30 Expected Graduation Date: ________________________

(Full-time undergraduate or graduate student--to be eligible for this reduced rate, attach a copy of your student ID and current class schedule indicating at least 12 credit hours per semester.) Student memberships are limited to a period of four years.

Other (please specify) _____________________________________

Which of the following best describes your current employment status? Please select one response.

Employed as a paid employee Self-employed Student full-time Not working--retired Not working--other Employer: (Company or Institution) ______________________________ Work Mailing Address: ____________________________________ City: ____________________________ State/Province: __________ Zip/Postal Code: __________________ Country: _______________ Phone: __________________________________________________ Cellular/Mobile Phone: ____________________________________ Fax: ____________________________________________________

Choose Payment Method

Individual Membership Dues $ ____________ AAMI Foundation Contribution (optional): 1. Healthcare Technology Safety Institute (HTSI) $ ____________

(aami.org/htsi)

2. The AAMI Foundation Scholarship Program $ ____________

(aami.org/foundation/scholarship)

Grand Total

$ ____________

The AAMI Foundation is an educational organization exempt from the 501(c)3 code of the Internal Revenue Service. Contributions to the AAMI Foundation are deductible as charitable contributions for federal income tax purposes to the extent provided by law. For U.S. Citizens only: AAMI dues are not deductible as a charitable contribution for U.S. federal income tax purposes, but may be deductible as a business expense.

Check is enclosed made payable to AAMI. (Checks must be in U.S. funds drawn on a U.S. bank.) Charge this to: VISA MasterCard AMEX

Card Number: ___________________________________________ Expiration Date: __________________________________________ Cardholder Signature: _____________________________________ Cardholder Name: ________________________________________

N E W M E M B E R A P P L I C AT I O N

About Your Membership

Your membership dues cover a 12-month period. A dues renewal notice will be mailed two months before your expiration date. Your membership dues include subscriptions to AAMI News, Horizons, and AAMI's journal, BI&T, which have a combined list price of $439 ($175, AAMI News; $70, Horizons; and $194, BI&T). Individual membership is not transferable to another individual. Please notify us if you have a change of address so you can continue receiving your membership benefits. Contributions or gifts to AAMI are not tax deductible as charitable contributions for federal income tax purposes; however, they may be tax deductible under other provisions of the Internal Revenue Code. We want to hear from you! We are constantly looking for ways to bring more value to your AAMI membership. Please let us know if there are any products or services that would help you in your work in the medical instrumentation and technology industry. Your ideas or suggestions help us develop additional benefits that would be of value to you as an AAMI member. Your input is greatly appreciated! ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Thank you for joining AAMI!

Member Information Submit Your Application

Call 800-332-2264, ext. 1214 (or 703-525-4890, ext. 1214 outside the U.S.), to charge your membership by phone. Mail membership form along with your check or credit card information to: AAMI, P.O. 890694, Charlotte, NC 28289-0694. Fax this membership form with credit card information to 703-525-1424. Complete the online application at www.aami.org/ membership and submit with credit card information.

Please complete this form and return along with your new membership application. Your help in providing this information assists us by making sure you only receive communications from AAMI that are of interest and value to your area of work. What is your main category of interest? Please select one response. Device Industry/Manufacturing Device User/Operator/Maintenance Regulator or other Governmental Agency General Interest sure/Don't know Not What is your primary job function? Please select one response. Asset Manager Biomed Equip Technician Biomedical Supervisor/Coordinator Central Supply CEO/President/Executive Management Clinical Engineering Department Manager Compliance Manager Consultant Educator

Engineer Engineer, Biomedical Engineer, Clinical Engineer, Product Engineer, Project Engineer, Quality Engineer, Design Engineer, Validation Healthcare Sterilization Professional Industrial sterilization Professional Imaging Equipment Service Specialist Information Systems Lab Director/Manager Laboratory Equipment Specialist Lawyer/Legal Counsel Microbiologist Nurse Physician/Surgeon Quality Assurance/Regulatory Affairs Research and Development Sales & Marketing Student Other (please specify) ______________________ _________________________________________

INDIVIDUAL MEMBERSHIP

What are your professional interests? Check all that apply. Ambulatory Care CE-IT Connectivity/Integration CAPA/Complaint Handling Dialysis Education/Training Electromagnetic Compatibility Equipment Design Facilities Design Planning Home Healthcare Human Factors Imaging Information Technology Manufacturing Materials management Operating Room Patient Monitoring Patient Safety Press Quality Assurance/Regulatory Affairs Radiology Repair & Maintenance Reprocessing/Reusables Research & Development Risk Management Sales & Marketing Software Engineering Sterilization, Industrial Sterilization, Healthcare Sterilization Technology Management Wireless Technology Other Medical Specialties (please specify) _________________________________________ _________________________________________ Other (please specify) ______________________ _________________________________________ _________________________________________

Please check your areas of expertise. Check all that apply Ambulatory Care CE-IT Connectivity/Integration CAPA/Complaint Handling Dialysis Education/Training Electromagnetic Compatibility Equipment Design Facilities Design Planning Home Healthcare Human Factors Imaging Information Technology Manufacturing Materials management Operating Room Patient Monitoring Patient Safety Press Quality Assurance/Regulatory Affairs Radiology Repair & Maintenance Reprocessing/Reusables Research & Development Risk Management Sales & Marketing Software Engineering) Technology Management Sterilization, Industrial Sterilization, Healthcare Sterilization Wireless Technology Other Medical Specialties (please specify) _________________________________________ _________________________________________ Other (please specify) ______________________ _________________________________________ Overall, how many years of experience do you have in the medical technology field? Please include the years at your current position and the years at all other related prior experience. Enter 1 for less than 1 year. # of years ________________________________

N E W M E M B E R A P P L I C AT I O N

Which of the following AAMI products, services, and benefits are you interested in? Check all that apply. Publications & Online Opportunities AAMI News AAMI News Weekly Standards Monitor Online AAMI Discussion Groups (eForums) AAMI Website (www.aami.org) AAMI Horizons AAMI Biomedical Instrumentation & Technology (BI&T) Non-Standards Publications Standards Documents Career Advancement Opportunities (job postings, resumes) Online Consultants/Medical Technology Directory Conferences/Meetings & Other Educational Opportunities Annual Conference & Expo Annual Conference to Exhibit Only AAMI Summits AAMI/FDA International Standards Conference ICC Certification (CBET, CRES, CLES) In-House Training Courses Quality Systems and Standards Courses Webinar/Distance Learning Participation Opportunities AAMI Publications (reviewing articles) AAMI Publications (writing articles) Committee(s) Participation (other than standards, TMC e.g., Awards Subcommittee, Editorial Board, etc.) Mentor/Mentee Opportunities Networking Opportunities Safety Council Working Groups Participation Standards Development/Committee Participation Speaking at AAMI Events Technology Management/Committee Participation Other (please specify) ______________________ _________________________________________

Are you a member of the C-Suite [e.g., CEO, CFO, or CTO]? Please select one response. Yes No Don't know/Not sure Do you have purchasing authority? Yes No Don't know/Not sure [ANSWER IF YOU HAVE PURCHASING AUTHORITY] Please select the one statement below that most accurately defines your purchasing authority. Please select one response. I have individual purchasing authority I have purchasing authority over an operating budget [ANSWER IF YOU HAVE PURCHASING AUTHORITY] What is the amount of your purchasing authority? Please select one response. Under $10,000 $10,000­$50,000 $50,001­$100,000 $100,001­$150,000 $150,001­$200,000 $200,001­$500,000 $500,001 to $1,000,000 $1,000,001 TO $2,000,000 OVER $2,000,000 Don't know

Next Are A Few Questions Related To AAMI Membership

Which of the following best describes who paid those dues? Please check one response. I pay my dues My employer and I pay the dues My employer pays 100% of the dues Never had AAMI membership Not applicable Don't know/not sure What is your biggest professional challenge? _________________________________________ _________________________________________

4301 N. Fairfax Drive Suite 301 Arlington, VA 22203-1633 T +1-703-525-4890 ext. 1214 T +1-800-332-2264 F +1-703-525-1424 www.aami.org

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