American Academy for Emergency Medicine in India
777 East Park Drive
PO Box 8820
Harrisburg, PA 17105-8820
Email: membership@aaemi.org
Personal Information*
*All information provided will be kept strictly confidential
First Name
Last Name
Home Address
City
State/Province
Zip/Postal Code
Country
Hospital / Place of Work
Business Address
City
State/Province
Zip/Postal Code
Country
Preferred Mailing Address Home Business
Date of Birth mm/dd/yyyy
Graduation Date mm/dd/yyyy

Residency Completion Date
mm/dd/yyyy

Occupation
Business Phone
Home Phone
Fax
E-Mail
Membership Dues:
Applicants from India/Sri Lanka
 Membership Category (Check one box)
Physicians ($75 annually)
Residents ($35 annually)
Students/Other ($20 annually)
Life ($300)
   

Membership Dues:
Applicants from Countries other
than India/Sri Lanka

 Membership Category (Check one box)
Physicians ($150 annually)
Residents ($75 annually)
Students/Other ($25 annually)
Life ($500)
   
Credit Card Type
Credit Card Number
(without spaces)
VPN (3 digit security number)
Expiration Date (mm/yy)

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If you prefer you can print the form and mail it with a check to:

AAEMI
777 East Park Drive
PO Box 8820
Harrisburg, PA 17105-8820

Thank you!