sEMCAN Network
Membership Application
Full Name
*
First Name
Last Name
Email
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example@example.com
ACEM membership number
What is your primary professional classification?
*
FACEM
ACEM Trainee
ACEM Certificant
ACEM Diplomate
ACEM Advanced Diplomate
ACEM SIMG
ACEM Staff
Country/State
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Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other
City/Town of residence
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Primary place of employment
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Please tell us about any special interests you have that may be relevant to this network.
By submitting I agree to receive news of sEMCAN activities and actively contribute to the Network.
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