I.E.M.R.A.
MEMBERSHIP APPLICATION
IF YOU DON'T HAVE INFORMATION FOR ONE OF THE QUESTIONS, PLEASE TYPE N/A IN THE LINE
INSTRUCTIONS:
-Complete Application In Full
-Provide Payment Information (payments may be made online on the MEMBERSHIP page)
-Include 2 Passport Photos With the Completed Application
-Mail (or email to info@iemra.com) Completed Application WITH Copies of Your:
--Driver's License
--Professional License
--Professional Degree
--Curriculum Vitae (or Resume)
--Current Student ID (if applicable)
*Incomplete applications cannot be processed. Please send full package with supporting documentation (application, passport photos, CV, copies of driver's & professional licenses, degree copy, student or veteran ID copy). Membership kits will be mailed in 6-8 weeks after receipt of membership dues and completed application with supporting documentation.
*Submitting the membership application denotes full acceptance of I.E.M.R.A. terms and conditions, privacy policy and COPPA policy.
MAIL COMPLETED PACKAGE TO: I.E.M.R.A.
35 East 38th Street, #10B, NY NY 10016, USA
Telephone: 1-347-271-1174
PERSONAL & CONTACT INFORMATION:
NAME:__________________________________________________________________
TITLE:__________________________________________________________________
DEGREE LEVEL OBTAINED:________________________________________________
SPECIALIZATION (if any):___________________________________________________
E-MAIL ADDRESS:________________________________________________________
OFFICE PHONE:__________________________________________________________
FAX NUMBER:____________________________________________________________
OFFICE ADDRESS:________________________________________________________
CITY, STATE, ZIP CODE:___________________________________________________
HOME ADDRESS:_________________________________________________________
CITY, STATE, ZIP CODE:___________________________________________________
HOME PHONE:___________________________________________________________
MOBILE PHONE:__________________________________________________________
ALTERNATE CONTACT INFO:_______________________________________________
EMERGENCY CONTACT (name, phone, address, relationship):_____________________
________________________________________________________________________
LEVEL OF MEMBERSHIP I AM APPLYING FOR:
Active Member (membership dues USD$350.)____________________________________
Reserve Member (membership dues USD$350.)__________________________________
First Responder Member (membership dues USD$99.)_____________________________
Student Member (include school name & expected date of graduation. Dues USD$50)____
MEMBERSHIP RENEWALS:
please include your application as well so we may update our records and any changes
ACTIVE RENEWAL (membership renewal dues USD$300.)______________________
RETIRED RENEWAL (membership renewal dues USD$300.)_____________________
SCHOLAR RENEWAL (membership renewal dues USD$200.)____________________
STUDENT RENEWAL (membership renewal dues USD$99.)_____________________
________________________________________________________________________
PERSONAL DESCRIPTION (for identification purposes):
HEIGHT:_________________________________________________________________
WEIGHT:_________________________________________________________________
HAIR COLOR:_____________________________________________________________
EYE COLOR:_____________________________________________________________
DATE OF BIRTH (mm/dd/yyyy):_______________________________________________
*Have you ever been convicted of a crime? If so, please explain.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
PAYMENT INFORMATION:
*Payment of membership dues may be paid online through the links below or on the MEMBERSHIP page. When mailing or emailing your application package to IEMRA, please include the payment transaction number, method and date of payment (PayPal, Visa, MasterCard, AmericanExpress) and copy of any receipt. Money Order payments must be included with the completed application package (if submitting the application package via email, please mail a copy with your money order payment). Applications without membership dues cannot be processed. Applications with any missing information or supporting documents cannot be processed. Please refer to the terms and conditions and contact us if you have any questions.
To process payment when submitting the application package, please provide information:
CREDIT CARD TYPE: _____Visa _____MC _____Amex
CARD NUMBER:__________________________________________________________
EXPIRATION DATE (mm/yyyy):_______________________________________________
3-DIGIT SECURITY CODE ON CARD BACK (CVV):______________________________
BILLING ADDRESS:_______________________________________________________
City, State, Zip Code, Apt/Suite, Country:_______________________________________
I acknowledge that I.E.M.R.A. will charge my account in the amount of USD$___________
for annual membership dues for the membership level of ___________________________
SIGNATURE:_____________________________________________________________
DATE:___________________________________________________________________
*For your convenience, would you like us to charge your card for future membership renewals? If so, please sign to accept below:
SIGNATURE:_____________________________________________________________
DATE:___________________________________________________________________
ACKNOWLEDGE AND ACCEPT:
*I certify that the above information is true and correct and I acknowledge that all credentials are the sole property of I.E.M.R.A. and can be revoked.
*I acknowledge that membership in I.E.M.R.A. is voluntary and can be terminated at any time, upon my request, or upon decision by I.E.M.R.A.
*I acknowledge that the term of membership is one (1) calendar year from the date of acceptance and issuance of I.E.M.R.A. credentials.
*I acknowledge that all renewals are for the term of one (1) calendar year from the date of expiration of initial acceptance and issuance of I.E.M.R.A. credentials.
*I certify that I understand and agree to all I.E.M.R.A. terms, conditions, policies and the information contained in this application.
SIGNATURE:____________________________________________________________
DATE:__________________________________________________________________
MEMBERSHIP LEVEL:_____________________________________________________
Please direct any and all questions and concerns to I.E.M.R.A. by telephone in the USA at 1-347-271-1174, by email at info@iemra.com or by post at I.E.M.R.A. 35 East 38th Street, #10B, NY NY 10016 USA.
We welcome all feedback and thank you sincerely.
