National Association of Emergency Medical Technicians



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National Association of Emergency Medical Technicians

MEMBERSHIP APPLICATION

Name (Please print or type) __________________________________________________________________________

Organization______________________________________________________________________________________

Address__________________________________________________________________________________________

City/State/ZIP______________________________________Country ___________________________οMale οFemale

Phone (Include area code) ________________________ Fax_______________________________________________

Email__________________________________________D.O.B._____________________________________________

State Certification No._____________________________and/or National Registry No.____________________________

Check ONE in each column.

Training Level/Position Participation Location

Active Member

οEMT-B οVolunteer οFire Dept. οPolice Dept.

οEMT-I οPart-time οHospital οIndividual

οParamedic οFull-time οMilitary οRescue Squad

οFirst Responder οIndustrial/Commercial

Associate Member οHealth Agency

οPhysician οPrivate Ambulance

οMedical Director οThird Serv. /Mun. Agency

οNurse οThird Serv. /Mun. Agency

οAdmin/Supervisor οOther____________________

οRetired

οOther________________________________

_____ Full Membership $40 per year

_____Affiliate Discount - $30 (for members of affiliated associations)

_____Military Discount - $25 (military rank of E-5 or below)

_____Student (EMT Program) Membership - $25 (good for one year only)

_____Squad Membership - $300 per year for up to 20 EMS professionals (application for each squad member required)

_____Total Due (US Dollars) - Enclose check payable to NAEMT

Please tell us who referred you to NAEMT:

NAEMT Member: _________________________________________________________________________________or

NAEMT Affiliate Organization: ________________________________________________________________________

I prefer to pay by: οVisa οM/C οAmEx Card No.____________________________________Expires____________________

Signature___________________________________________________________________________________________________

Online application available at:

or send completed application to: NAEMT, Post Office Box 8539, Columbus, MS 39705

Upon acceptance of this application, you will receive a confirmation via email with your membership ID number.

Questions? Please visit , or call 1-800-34-NAEMT, fax 601-924-7325, or email membership@

50090000000200000

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Military Only

Rank (E5 or below) _______________

οActive οReserve

MOS___________________________

οAir Force οArmy

οMarine Corps οNavy

οCoast Guard

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