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

SAEM Resident Member Group Application

Make additional copies of this form as needed
(Please type)

Name of Institution: _________________________________________________________

Number of Residents in Program: __________________

Number of Residents applying for membership: ________________ X $90= ______________

Contact if questions: _____________________________ Phone: ______________________

  1. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  2. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  3. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  4. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  5. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  6. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

  7. Name of resident: ______________________________________________________

    Home Address: _______________________________________________________

    City:_________________________ State: ______________ Zip: ________________

    Anticipated graduation date from program (year): __________________

    Preferred address for mailings: home business

    Return to the [SAEM] HomePage