Network application - Private Emergency Medicine

Private Emergency Medicine Network

Membership Application
Full name*

First NameLast Name
Email*
example@example.com
ACEM membership number
What is your primary professional classification?*

FACEMACEM TraineeACEM CertificantACEM DiplomateACEM Advanced DiplomateACEM SIMGAllied Health WorkerMedical AdministrationMedical Officer/InternNursing StaffOther Specialty ConsultantOther Specialty TraineeParamedicResearch StaffOther
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 ZealandAustralia Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaOther
Country/State*
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?*

YesNo
Hospital name*
Are you undertaking research related to private emergency medicine?*

YesNo
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.*

YesNo
By submitting I agree to receive news of PrEMN activities and actively contribute to the Network.
Should be Empty:

Private Emergency Medicine Network