Simply print out and complete the form below and mail it to:
National Emergency Medicine Association Name: _____________________________________________________ Address: ___________________________________________________ City: ___________________________State:________Zip:___________ Country (if not USA): __________ Email:____________________________________________________ I wish to support: $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! Home
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