901 N. Washington Avenue Lansing, Michigan 48906-5137 Telephone: (517) 485-5484 FAX: (517) 485-0801 E-Mail: saem@saem.org

SAEM Membership Application

SAEM 901 N. Washington Ave. Lansing, MI 48906 (517) 485-5484; (517) 485-0801 Fax; e-mail: saem@saem.org

(Note: on some computers, this form may require that you widen your web-browser window to view it correctly).

Name_________________________________________________________ Title: MD DO PhD Other_________

Birthdate________________ Sex: M F

Home Address_____________________________________________________________________________

_________________________________________________________________________________________

Business Address _________________________________________________________________________________

_________________________________________________________________________________________

Preferred Mailing Address (please circle): Home Business

Telephone: Home (_______)_______________________ Business(_______)___________________________

Fax:___________________________ E-Mail:___________________________________________

Medical School or University Faculty Appointment and Institution (if applicable)________________________________________________________________________

Check the appropriate membership category:

__Active __Associate __Resident __ Fellow __Medical Student

Membership benefits include:

• subscription to SAEM's monthly, peer-reviewed journal, Academic Emergency Medicine
• subscription to the bimonthly SAEM Newsletter
• reduced registration fee to attend the SAEM Annual Meeting

Note: Because SAEM is a non-profit organization all dues paid are tax deductible by you or your organization as either a business expense or charitable donation.

Active: individuals with an advanced degree (MD, DO, PhD, PharmD, DSc or equivalent) who hold a university appointment or are actively involved in Emergency Medicine teaching or research. Annual dues are $365. The application must be accompanied by a CV.

I attest that I hold a university appointment or am actively involved in Emergency Medicine teaching or research:
___ Yes ____No

Associate: health professionals, educators, government officials, members of lay or civic groups, or members of the public who have an interest in Emergency Medicine. Annual dues are $350. The application must be accompanied by a CV.

Resident: residents interested in Emergency Medicine. Annual dues are $90. My anticipated date (month and year) of residency graduation is _______. (A discounted group resident member rate is available. Contact SAEM for details).

Fellow: fellows interested in Emergency Medicine. Annual dues are $90. My anticipated date (month and year) to complete my fellowship is _______.

Medical Student: medical students interested in Emergency Medicine. Annual dues are $75 (includes journal subscription). My anticipated date (month and year) of medical school graduation is _______.

Interest Groups: SAEM members are invited to join interest groups. Include $25 annual dues for each interest group membership:

__airway ___clinical directors __CPR/ischemia/reperfusion __disaster medicine __diversity __EMS __ ethics
__ evidence based medicine __ geriatrics __health services and outcomes research __international emergency medicine
__ mentoring women __ medical student education __ neurologic emergencies __ palliative medicine
__ patient safety __pediatric emergency medicine __ public health __research directors __ simulation
__ trauma__triage __ toxicology __ ultrasound __ uniformed services __ web educators

My signature certifies that the information contained in this application is correct and is an indication of my desire to become an SAEM member.

Signature of applicant____________________________________________________________Date__________________

SAEM does not sell or otherwise provide SAEM membership information or the SAEM mailing list for any non-SAEM activities.

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