ACOEP Retired Member Application

Retired Member Application

Complete the application below to apply for Retired Membership
Thank you for applying for Retired Membership. With Retired Membership, your annual membership dues will be decreased to $500/year. Please complete the application below to determine that the criteria apply to you. Please note: Retired Membership rates go into effect during the next dues cycle after granting of this status.
Applicant's Full Name*

First NameLast Name
Email*
example@example.com
Retired Membership status may be granted to any ACOEP member upon applications to the Member Services Committee who meets the following criteria:
- At least 60 years of age
- Fully retired from Emergency Medicine
Please acknowledge that the three criteria above are met:

At least 60 years of ageFully retired from Emergency Medicine
ACOEP Membership Join date: *
ACOEP Membership Join date: *
Year of Official Retirement from Emergency Medicine*
Anything else the Membership Committee should know?
I certify that I am officially and permanently retired from the practice of Emergency Medicine and that the information in this application is true and complete to the best of my knowledge.
Signature*

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Date*

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Date
Applications must be received at least (30) days prior to the next scheduled Committee meeting in order to be considered at the upcoming Spring Seminar or Scientific Assembly. You will be notified within (60) days of the Committee review of your member status. Any further questions or concerns, please contact us at info@acoep.org.
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