Application for FREE 2009 – 2010 OEMSA Membership

DEADLINE FOR APPLICATION: JUly 31, 2010

 

As an OEMSA member, one of your benefits is access to a member’s only forum where you can place questions and comment on postings. This is a password-protected forum. It is a requirement of the forum that all users must be identified. To be able to identify and verify members meet membership requirements, we require the following:

Name:

DOB:                            Sex:

Address:

Address:

City:

State:

Zip:

Contact Phone:

EMS level (First Responder, EMT-B, EMT-I, Paramedic, RN, PA, MD/DO):

Certification/License #:                          Exp. Date:

Total years in EMS:

Years in EMS at current certification/license level:

#1 EMS Agency Affiliated with:

City

State:

Phone:

#2 EMS Agency Affiliated with:

City

State:

Phone:

Do you wish to participate in the OEMSA Forum (Yes/No):

If you say NO, you will still receive e-mail updates from OEMSA on educational activities, etc. If you say YES, you will be given a access to the OEMSA Forum and be governed by forum rules.

Are you interested and available to help OEMSA in any of the following areas:

Website design and/or management:

Membership Recruitment:

Recruiting Sponsors:

Writing News R4eleases:

Political Action:

Other:

 

 

Return this form to: Pres@OregonEMS.Org