Categories and Benefits Collaborate with Industry Advertising Corporate Membership Application Astro Form Text - Company Info Company Information Company Name Street Address City State Zip Code Country Phone Number Email Company Website Company Description Social Media Handle(s) Astro Form Text - Primary Contact Primary Contact Name Title Email Astro Form Text - Secondary Contact Secondary Contact Name Title Email Astro Form Text -Other Contact Other Contact Name Title Email Astro Form Text - Company Type Company TypePlease select all that apply. Multiple choice - Company Type Ancillary Products and Devices Artificial Intelligence Brachytherapy External Beam RT Imaging Immunotherapy Information/Technology Liquid Biopsy Patient Handling/Positioning Pharmaceuticals Practice Management Quality Assurance Radiopharmaceuticals Treatment Delivery Other, please specify Other Company Type Astro Form Text - Products Please indicate principle product(s)/service(s) in radiation oncology to facilitate membership approval: Product(s)/Service(s) Astro Form Text - ASTRO References Please provide two names of active ASTRO physician members as references (You will be notified if we need to contact your references). Reference 1 Reference 2 Astro Form Text - Financial Commitment Financial Commitment (based on annual sales volume in radiation oncology)* Radio buttons - Financial Commitment Up to $10 million = $3,000 $10 million to $100 million = $4,000 100 million + = $5,000 Astro Form Text - Final text *Please do not send payment with your application. ASTRO will invoice once application is approved for membership by the Board of Directors. Payment must be received within 120 days of membership approval to avoid cancellation. Rates are not pro-rated throughout the year. The undersigned understands that participation in the ASTRO Corporate Membership Program requires the corporation to be generally acceptable to the ASTRO membership; consistent with ASTRO’s goals and objectives; committed to the aims of the radiation oncology profession; and accessible to a broad segment of the profession. Participation in the ASTRO Corporate Membership Program is at ASTRO’s sole discretion. Submitter Name Date
