Address  ………………………………………………………………………………Suburb:………….. ……………..

                                              Country if not                                                                                                     

State  ……P/Code  …………Australia: ………………………      Email address: (Write clearly Please!!) :…………………………………….

Please circle the most appropriate category box that characterizes your association in Emergency Medicine (EM)

• ACEM Fellow  
  
  
• ACEM Trainee   
  
  
• GP 
  
  
• CMO 
  
  
•  HMO with a significant involvement in EM
  
  
• Other Specialist
  
  
• GP 
  
  
• CMO
   
  
• HMO with a limited involvement in EM
  
  
• Nurses o Ambulance Officer. o Health Administrator   Please specify ……………………………………
  
  
• Institution conducting an emergency department service  (Contact person’s name nominated above)

AND remember to also circle the type & level of subscription requested:

•       Full or Associate Member (with EMA Journal)       AUD $276 p/a 

•      Full or Associate Member (without EMA Journal)  AUD $171 p/a    

•      Institutional members (with EMA journal)               AUD $386 p/a     

NB:ACEM Fellows and Trainees automatically receive the Journal as part of their Annual Australasian College for Emergency Medicine subscription.

------------------------------------------------------------------------------------------------------------------------------------------------

Please indicate your preferred Method of payment HERE:

• cheque (made payable to Australasian Society for Emergency Medicine) or,
  
  
• credit card  (complete the section below)

Total payment:                        $……………….

Please debit my ASEM subscription of AUD$ ................….. to my  ɤ BankCard    ɤ Mastercard    ɤ Visa card  (please specify)

(Card Number):                                                                             (Expiry Date):

Cardholder’s:

Name on card ...................................................  Signature ........................................................ Date: ......../......../200….

(Please return payment to ASEM by fax or letter to the above address.. Receipts will be returned by mail, fax or email)

NB. As a non profit association, no GST has been allotted to this account by the ASEM

------------------------------------------------------------------------------------------------------------------------------------------------

PRIVACY STATEMENT:        The ASEM respects and adheres to all privacy requirements under the State & Federal Legislations.