Simply print out and complete the form below and mail it to:

National Emergency Medicine Association
306 W. Joppa Road
Baltimore, Maryland 21204-4048

Name: _____________________________________________________

Address: ___________________________________________________

City: ___________________________State:________Zip:___________

Country (if not USA): __________


I wish to support:
NEMA_____The National Heart Council_____
The National Stroke Council_____
The Seniors Life Council_____
Kids Do Matter_____
The Heart of the Matter_____
In the amount of:

$5.00_____ $7.00_____$10.00_____ $15.00_____$20.00

$25.00_____$50.00_____ other______

Method Of Payment:

Check_____ Money Order _____ Visa* _____ Mastercard*_____

*Account Number ____________________________________

*Expiration Date ______________________


*Signature: ______________________________Date:_____________________

Thanks for your generous support!