SMEMSIC Membership Application Form

Please provide the following information: Do not hit the enter key on your keyboard or the form will be submitted before you have completed the form. Use the tab key or your mouse to navigate between fields. When you click on the submit button at the bottom of this page, you will be directed to the payment page. Be sure you enter your first and last name in the payment area of the payment page so that your payment will be matched with this form.

Please select the EMS Region you live or work in from the list below.

Region 1
Region 2
Region 3
Upper Peninsula
Other

Member Contact Information
Please complete the information below.

First Name

Last Name

Address 1

Address 2

City

State

Zip / Postal Code

Home Phone

Work Phone

E-mail

Fax

First Name
Last Name
Address 1
Address 2
City
State
Zip / Postal Code
Home Phone
Work Phone
E-mail
Fax