To Become a Member

The CyberKnife Coalition 2010 Membership Application

Information and Instructions Regarding Membership Application

On behalf of the CKC membership, the CyberKnife Coalition will from time to time, interact with and advise the appropriate government regulatory agencies and other medical professional societies. By becoming a member of this organization, you agree to be represented in this manner.


Membership Qualifications
A Candidate for Membership in the Coalition shall meet the following qualifications:

1. The Candidate shall be in an administrative role related to the operational management of a CyberKnife Center.
2. The Candidate shall be employed by an entity that has control or majority influence over the operational management of a CyberKnife.
3. The Candidate must submit an application with accurate and verifiable information. Discovery that information is not accurate or verifiable is cause for denial or termination of membership.

Website Access

Upon acceptance, access to CyberKnife Coalition members only section of the web site will be available, once a username and password is assigned.

Member Category, Annual Membership Fee and Voting Privileges:

$1000. USD
 $2000. USD
 $5000. USD
     List Vendor product or service
      
    Membership is assigned to the center. Individuals are identified for CKC communications and directory listing only and may be changed as needed.
    Center Name for Directory Listing:
      
    Primary Contact:
    *Last:*First:
      Professional Degree(s):(MHSci, MS, MD, DO, PhD, RN, RT, etc.)
    *Title:
      Affiliation: 
    *Phone:  Fax: 

    *Email Address:

      Assistant Name:

      Assistant Phone:
     
      Additional Contacts for CKC communications:
      Name:  Email: 
      Phone:  Fax: 
     
      Name:  Email: 
      Phone:  Fax: 
     
    Preferred Mailing Address: (for membership directory listing)
    *Address:
    *City:
    *State: 
    *ZIP:
     
    Alternate Mailing Address:
    C/O:
    Address:
    City:
    State: 
    ZIP:
     
    CyberKnife Location:
    Ownership:
      
      
    Hospital:
    Free-standing Center:
    Other location: 
     

    Approximate Number of CyberKnife Cases Performed:

    2005
    2006
    2007
    2008
    2009
     
    Type(s) of CyberKnife Cases Performed:
      
      
        
        
        
     
    Authorizations:
    I authorize the use of our institution name on CyberKnife Coalition letterhead.
    I authorize the use of our institution name in the Member section of the CKC web site.
    I request that our institution logo and web site link be included on the CKC web site.