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.

Drop your files here

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.

Continuing Certification

Are you actively participating in EMS Continuing Certification?

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

ABMS/ABEM Volunteer Experience (if applicable)

Item Writer

Item Writer Dates

Oral Examiner

Oral Examiner Dates

Other ABMS/ABEM Volunteer Appointments (Please specify)

Statement of Interest

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