American Academy for Emergency Medicine in India
777 East Park Drive
PO Box 8820
Harrisburg, PA 17105-8820
Email: membership@aaemi.org

Registration will include
Discounted and free registration to certain AAEMI conferences and endorsed events
1 year subscription to the International Journal of Emergency Medicine (IJEM)
For life members it will include a 5 year subscription to IJEM.

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 ($200 annually)
Residents ($100 annually)
Students/Other ($25 annually)
Life ($800)
   
Credit Card Type
Credit Card Number
(without spaces)
VPN (3 digit security number)
Expiration Date (mm/yy)

Clicking the "Submit" button once will take you to our secure server

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!