Join AAEM Name* First Last Title(s) Business InformationBusiness Name Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact InformationBusiness Phone Number*Business FaxMobile PhoneHome PhoneEmail Address* Website Personal InformationHighest Education LevelUndergraduateGraduatePost GraduateLicensure State Licensure Certificate Number Attach CVMax. file size: 256 MB.Attach Photo/Headshot (optional)Max. file size: 256 MB.Have judgments or verdicts been made against you in professional liability cases?* Yes No Has your license to practice medicine or any other health care profession in any jurisdiction ever been suspended or revoked?* Yes No Have you ever been denied membership, or renewal thereof, or been subject to disciplinary action in any medical organization or any other health care profession?* Yes No Please state your reason for wanting to join the Academy: CertificationsCertifications (check all that apply) Allergy / Immunology Anesthesiology Colorectal Surgery Dermatology Emergency Medicine Environmental Medicine Family Practice Internal Medicine Neurological Surgery Nuclear Medicine Obstetrics / Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine / Rehabilitation Plastic Surgery Preventive Medicine Psychiatry / Neurology Radiology Surgery Thoracic Surgery Urology Other If you selected other what is your Certification? SpecialtiesSpecialties (check all that apply) Acupuncture Adolescent Medicine Allergy Chelation Clinical Immunology Dermatology Environmental Medicine Family Practice Homeopathy Immuno-Metabolic Disorders Internal Medicine Non-Toxic Dentistry Nutritional Medicine OB/GYN Otolaryngology Pediatrics Preventive Medicine Psychiatry Toxicology Urology Other If you selected other what is your Specialty? How did you hear about us?How did you hear about us?*AAEM WebsiteFacebookInstagramLinkedInAAEM ConferenceBraden KulikAAEM Member ReferralOtherIf you were referred by another AAEM member who referred you? If you selected "Other" above how did you hear about us? Δ
