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
-----------------------
Military Only
Rank (E5 or below) _______________
οActive οReserve
MOS___________________________
οAir Force οArmy
οMarine Corps οNavy
οCoast Guard
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