Membership Application
SOUTHERN SOCIETY OF ELECTRONEURODIAGNOSTIC TECHNOLOGISTS, INC.
Applicants for membership must meet the following requirements:
1. Must be working or training under in the field of Electroneurodiagnostics, Polysomnography or a related field.
2. Must have been working or training as above within the six months proceeding the application.
3. Submit application to: SSET Membership c/o Kimberly Ann Ellis, CNIM, R. EEG/EP T. 2325 Maben Ave, Palm Harbor, FL 34683
Dues of $30.00 payable to SSET.
Name:______________________________________________________________________________________
Professional Registry_________________________________________________________________________
Home Address:______________________________________________________________________________
___________________________________________________________________________________________
Business Address:____________________________________________________________________________
___________________________________________________________________________________________
E-mail Address:_____________________________________________________________________________
Home Phone:_________________________________Business Phone:_________________________________
Period of time in EEG field:___________________________________________________________________
Where trained and for how long:_______________________________________________________________
___________________________________________________________________________________________
Medical head of your department:______________________________________________________________
Literature to be sent to: ( ) Business Address ( ) Home Address
Date:__________________ Signature:___________________________________________________________
Please send applications or inquires to:
Kimberly Ann Ellis, CNIM, R. EEG/EP T,*SSET Membership Chair*
