2024 EMS Subboard Member Application Form

2024 EMS Subboard Member Application Form

Applicant Information

Applicants will be asked to update their demographic information within the ABEM portal.

Full Name*

Professional Photo (optional)

Upload a recent professional photo or send to nkazerani@abem.org.

Drag and drop files here or

City, State*

Email Address*

Phone Number*

Current Position*

Description of Current Practice in EMS*

Please include practice setting, % of time spent in EMS, and description of EMS clinical work.

Are you actively participating in EMS Continuing Certification?*

Select or enter value

If maintaining primary certification, are you actively participating in your primary specialty’s continuing certification program?

Select or enter value

Item Writer

Item Writer Dates

Oral Examiner

Oral Examiner Dates

Other ABMS/ABEM Volunteer Appointments (Please specify)

Please provide a statement of interest in serving on the EMS Subboard.*

Why do you want this opportunity?

Applicant Signature (type full name):*

By providing your typed signature, you are attesting that the information you have provided is correct and true to the best of your ability.

Date*

Send me a copy of my responses