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AEP.org :: Online Membership Application

Online Membership Application

Please read before proceeding-

There are two steps in completing the membership application process for AEP.

The first step is completing the application below with as much information as can be provided.. After you submit your application, you will be forwarded to the payment screen where you'll be prompted to make your payment using PayPal.
The second step is submission of payment. Select the appropriate membership option (Regular membership - $250.00/year; Associate - $125/year; for the Lifetime Membership use the mail-in application). You will then be forwarded to PayPal where you can submit your payment using your credit card. If you don't have a PayPal account, you'll have to sign up when you get through this step. It's a simple process. When you do submit payment, make sure that the name on the PayPal account is the same as on the application or make note of any discrepancy so we know who the payment is from. Both of these steps must be made one after the other in order to complete the application process.

If you prefer, you may submit your application by "snail mail" and send along a check for payment (see below).

Once received, your application will then be reviewed. Upon approval, we will send notification of acceptance and your AEP membership information (for new members), including a username and password to access the Members-Only Section on the website. If you are renewing your membership, your username and password will remain the same. We will notify you that we have received your renewal payment.

If you have any problems with this process or you don't receive notification of receipt of your application and payment, please contact the AEP Executive Director (execdir@aep.org).

If you prefer not to pay online with your credit card using PayPal, please download and print the membership application by clicking here.

If you choose this option, please submit your completed application and payment in full to the AEP Office at the address on the application form.

Thank you!

	All fields are required unless marked with an "*"
	New Member
First name:
Last name:
Credentials:
Primary Email Address:
Occupation / Work Information:
Current place of employment:
Job title:
Department:
Street address:
City/State/Zip code:
Work phone:
Fax*:
Years at this position:
Names and addresses of two references who can verify my work as an emergency physician:
1.
2.
Home Information:
Spouse's name*:
Street address:
City/State/Zip code:
Home phone:
Fax*:
I would prefer my mail to go to my:
Professional Information:
1. Medical School and month/year of graduation:
2. Internship / Residency and month/year of graduation:
3. Fellowship(s):
4. Board certification(s):
5. Special recognitions*:
6. Membership in other professional organizations*:
7. States in which you hold active medical licenses:
8. With regards to your current employment situation, are you / your group*:	- hospital employee(s) - independent contractor - part of an independent group, contracted with hospital - employed by a larger contract group, with whom the hospital has an agreement - Other If, other:
9. Do you practice Emergency Medicine:
How many hours per week?
How many years in EM practice?:
10. Academic appointments*:
11. Involvement with EMS (eg, Medical Director)*:
12. Other information that you would like to provide*:
13. How did you hear about AEP? (check one)*:	- AEP Website - Referred by: - Ad - Other If, other:
Primary reasons for joining AEP and ways in which I would like to be actively involved in AEP:
Attestation Statement:	By submitting this application using the "Submit" button below, I testify that the information provided in this application is true and accurate to the best of my knowledge. I will provide the organization, AEP, and its Board of Directors with any supporting documents requested to support this information and these claims. I understand that providing false information may be considered grounds for dismissal from AEP. I understand that all Dues Payments and Fees, including Lifetime Dues, are Non-refundable.