I.E.M.R.A.
MEMBERSHIP APPLICATION
Name
Title
Zipcode
Fax
Office Address
City
Home Address (for mailing)
City
E-Mail
Degree
Office Phone
Specialty
State
State
Zip Code
Home Phone
Fax
I am applying for membership as a(n):
Membership kits will be issued upon full payment of applicable dues, receipt and confirmation of proof of membership requirements (allow 6-8 wks for delivery).
Hair Color
Height
D.O.B.
Weight
Eye Color
I certify that the above information is true and correct and I acknowledge that all credentials are the sole property of the I.EM.R.A. and can be revoked.
Name of Applicant
Date
Payment Options
IF YOU DON'T HAVE INFORMATION FOR ONE OF THE BOXES
PLEASE TYPE N/A IN THE BOX
I acknowledge that I.E.M.R.A. is a private organization that is not affiliated with any government agency. I also acknowledge that my information will be kept on file with I.E.M.R.A. and that membership entitles me to no privileges or immunities. Sumbitting the membership application denotes full acceptance of the I.E.M.R.A. terms and conditions, privacy policy and COPPA policy.
SIGNATURE:
Member of which Veterans' Organization
Please print or scan a copy of the application and mail or email it to I.E.M.R.A. along with a copy of the required documents: copy of your professional & driver's license, 2 passport photos (white background only), Curriculum Vitae, & a copy of your current veterans' organization membership card.
Have you ever been convicted of a crime? If so, please explain (charge, where, when, details).
PLEASE BE ADVISED THAT THIS FORM IS ONLY THE APPLICATION FOR MEMBERSHIP. PAYMENTS MUST BE SUBMITTED VIA THE WEBSITE (WWW.IEMRA.COM). PAYPAL AND CREDIT CARD PAYMENTS ARE ACCEPTED. PLEASE CLICK THE APPROPRIATE BUTTON ON THE NAVIGATION MENU TO MAKE CREDIT CARDS PAYMENTS (WITHIN THE UNITED STATES ONLY) OR PAYPAL PAYMENTS (ALL FOREIGN ORDERS MUST BE PAID VIA PAYPAL).
