SEMCAN Network
Membership Application
Full Name
*
Title
First Name
Last Name
Email
*
example@example.com
Are you an ACEM member or trainee?
Yes
No
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ACEM Membership
ACEM membership number
*
Membership category
*
ACEM Advanced Diplomate
ACEM Associate (Foundation EM Associate)
ACEM Associate (Advanced)
ACEM Associate (Intermediate)
ACEM Certificant
ACEM Diplomate
ACEM Fellow – FACEM
ACEM International Affiliate Member
ACEM PHRM Associate
ACEM Retired Fellow
ACEM Trainee – FACEM
ACEM Trainee – Associateship
Other (please specify)
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Categories
Please select the category that best describes you
*
Nurse or Registered Nurse
Allied Health Professional
Medical Trainee
Medical Doctor
Prevocational Doctor
Other
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Where are you located?
Country/State
*
Aotearoa New Zealand
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Other (please specify)
City/Town of residence
*
Where is your primary workplace?
*
For example Royal Hobart Hospital
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What interests you?
Please select all you are interested in:
*
Education
Research
Advocacy
Governance
Engagement
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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