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AEP.org :: Online Renewal Application

Online Renewal Application

Please read before proceeding-

Please take a few minutes to review your invoice and update your Personal Profile. In coming months, AEP will be using internet e-mail and website links to communicate with you. Electronic communication means more current, up-to-date news and correspondence. We will be able to use the monies saved on rising paper, postage, and production costs for advocacy and programs for you. Having your current e-mail address is essential. Please update your e-mail address and notify us of any contact information changes if/when they occur. Thank you in advance!

How it works
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'll be forwarded to the payment screen where you'll be prompted to make the payment using PayPal with your credit card.
The second step is submission of payment. If you don't have a PayPal account, you'll have to sign up when you get to 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.

Once received, your application will then be reviewed. Your AEP 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 "*"
	Renew membership till June, 2011
First name:
Last name:
Work Information:
Current place of employment:
Job title:
Department:
Street address:
City/State/Zip code:
Work phone:
Fax*:
Home Information:
Street address:
City/State/Zip code:
Home phone:
Email address:
I would prefer my mail to go to my:
Membership Options/Cost:
Regular (actively practicing emergency physicians):	$250.00
Associate:	$125.00
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.