Member Application (Paramedic / Communications / EMR) Subscription Personal Info - PAM

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Member Application (Paramedic / Communications / EMR) Personal Info

Salutation

Full Legal Name

First Name *

Middle Name

Last Name *

Preferred Name

Primary Address

Address Line 1

Address Line 2

City

Country

Province/State

Postal/Zip

"Other Region" is only used for International addresses

Home Phone

Cell Phone

Would you like to receive text messages from PAM?

Yes

Primary Email *

Secondary Email

Date of Birth

Certificate of Practice Designation

EMR

PCP

PCP-IC

ACP

CCP

College Registration Number *

New Members - enter 99999

Licence Expiry Date

Year Started in EMS

Education

Check ALL Applicable

Academic Status

High School

Diploma

Bachelor

Masters

Enter Primary Employer

Select NONE if you have no employer

Primary Employer *

Primary Employment Status

Full-Time

Part Time: Enter EFT equivalency (ex. .5)

Casual

Volunteer

None

Enter Secondary Employer

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Secondary Employer

Languages Spoken

Membership Valid from

Membership Valid to

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Password *

Password Confirmation *