Corporate Membership Application MIRS – 2017
This information is collected for use by MIRS officers only and will not be shared with anyone outside of this organization. Please fill out this form, print, and mail it in with a check made payable to MIRS. Additional information is provided below.
Membership Category Applying for (check one):
Corporate membership fees include the MIRS meeting registration. The Corporate membership fee includes space for a table top display.
• Platinum Corporate members have 2 spaces for a table top display, and multiple delegates may attend the meeting
• Gold Corporate members have 2 spaces for a table top display, and 4 delegates may attend the meeting.
• Silver Corporate members have one space for table top display and up to 2 delegate may attend the meeting.
• Bronze Corporate members are very small companies/start-up companies only – especially if new to MIRS. Bronze Corporate members have one space for table-top display and only 1 delegate may attend the meeting.
• Table top displays will be exhibited during the meeting on Saturday October 28, 2017.
p Platinum Corporate Membership ($5000)
p GOLD Corporate Membership ($4000)
p SILVER Corporate Membership ($2500)
p BRONZE Corporate Membership ($1500)
Applicant Name:
(Last name) (First name) (M.I.)
Corporation Name:
Mailing Address: City/State/Zip: Business Phone: Corp URL:
E-mail Address:
(MIRS program updates will be sent via e-mail)
Please DO NOT put me on the MIRS email list.
Where did you hear about MIRS? MIRS Mailing
Vendors Representative
From a Colleague From the Internet Other:
Please fill out the following for designated Corporate representative(s) at the 2017 Annual MIRS meeting:
Delegate 1:
(Last name) (First name) (M.I.)
Mailing Address: City/State/Zip: Business Phone: Fax Number:
E-mail Address:
Delegate 2:
(Last name) (First name) (M.I.)
Mailing Address: City/State/Zip: Business Phone: Fax Number:
E-mail Address:
****Additional delegates for Gold and Platinum Corporate membership can be listed on a separate piece of paper
Please mail this membership form and a check payable to MIRS to:
Attn: Donnell Williams
Arkansas Children's Hospital
#1 Children’s Way
Department of Radiology, Slot 105 Little Rock, AR 72202
Fax: 501-364-1282
Questions should be directed to Donnell Williams at 501-364-4914 or