Private Emergency Medicine Network
Membership Application
Full name
*
First Name
Last Name
Email
*
example@example.com
ACEM membership number
What is your primary professional classification?
*
FACEM
ACEM Trainee
ACEM Certificant
ACEM Diplomate
ACEM Advanced Diplomate
ACEM SIMG
Allied Health Worker
Medical Administration
Medical Officer/Intern
Nursing Staff
Other Specialty Consultant
Other Specialty Trainee
Paramedic
Research Staff
Other
Are you any of the following?
*
Director of Emergency Medicine (DEM)
Director of Emergency Medicine Training (DEMT)
None of the above
Country/State
*
Aotearoa New Zealand
Australia Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other
Country/State
*
Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
City/Town of residence
*
Street Address
Street Address Line 2
State/Town
Postal / Zip Code
What is your primary place of employment?
*
(e.g. Auckland City Hospital)
Are you employed in a private ED?
*
Yes
No
Hospital name
*
Are you undertaking research related to private emergency medicine?
*
Yes
No
Please tell us about any special interests you have that may be relevant to this Network (clinical/research/other)
*
By submitting I agree to receives news of PrEMN activities and actively contribute to the Network.
*
Yes
No
By submitting I agree to receive news of PrEMN activities and actively contribute to the Network.
Submit
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