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    IAEM Associate Membership Application Form Page 1 121113

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    Honorary Secretary: Honorary Treasurer: Dr. Aoife Thomas Dr. John Murphy Dr. Paul O’Reilly Registrar in Emergency Medicine Consultant in Emergency Medicine Consultant in Emergency Medicine Cork University Hospital Cork University Hospital Midland Regional Hospital Wilton, Cork Wilton, Cork Mullingar, Co. Westmeath Ireland Ireland Ireland Tel: +353 21 4922000 Tel: +353 21 4922000 Tel: +353 44 9385000 Email: aoife.thomas@hse

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    IAEM Associate Membership Application Form Page 1 121113

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    louglee9174
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    Honorary Secretary: Honorary Treasurer: Dr. Aoife Thomas Dr. John Murphy Dr. Paul O’Reilly Registrar in Emergency Medicine Consultant in Emergency Medicine Consultant in Emergency Medicine Cork University Hospital Cork University Hospital Midland Regional Hospital Wilton, Cork Wilton, Cork Mullingar, Co. Westmeath Ireland Ireland Ireland Tel: +353 21 4922000 Tel: +353 21 4922000 Tel: +353 44 9385000 Email: aoife.thomas@hse

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    Honorary Secretary: Honorary Treasurer: Dr. Aoife Thomas Dr. John Murphy Dr. Paul O’Reilly Registrar in Emergency Medicine Consultant in Emergency Medicine Consultant in Emergency Medicine Cork University Hospital Cork University Hospital Midland Regional Hospital Wilton, Cork Wilton, Cork Mullingar, Co. Westmeath Ireland Ireland Ireland Tel: +353 21 4922000 Tel: +353 21 4922000 Tel: +353 44 9385000 Email: aoife.thomas@hse

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    Download as PDF, TXT or read online from Scribd
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    12 views1 page

    IAEM Associate Membership Application Form Page 1 121113

    Uploaded by

    louglee9174
    Honorary Secretary: Honorary Treasurer: Dr. Aoife Thomas Dr. John Murphy Dr. Paul O’Reilly Registrar in Emergency Medicine Consultant in Emergency Medicine Consultant in Emergency Medicine Cork University Hospital Cork University Hospital Midland Regional Hospital Wilton, Cork Wilton, Cork Mullingar, Co. Westmeath Ireland Ireland Ireland Tel: +353 21 4922000 Tel: +353 21 4922000 Tel: +353 44 9385000 Email: aoife.thomas@hse

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    Royal College of Surgeons in Ireland.

    123 St Stephens Green,


    Dublin 2,
    Ireland.
    www.iaem.ie
    www.emergencymedicine.ie

    IAEM ASSOCIATE MEMBERSHIP APPLICATION FORM


    PROFESSIONAL DETAILS
    Title: Dr/Mr First Name: ______________________________________________________
    Surname: ___________________________________________________________________

    Current post: _________________________________________________________


    ___________________________________________________________________
    Category (Circle as appropriate): SpR / Registrar / SHO / Intern / Staff Grade / AEP / Other (specify):
    _________________________________________________________________________________________

    Work Address: ___________________________________________________________________


    ________________________________________________________________________________

    CONTACT DETAILS
    Preferred contact address (Circle as appropriate): Work / Other
    Other Address: _____________________________________________________________________
    _________________________________________________________________________________
    _________________________________________________________________________________
    Work telephone No: ________________________ Email: _______________________________________
    Mobile telephone No: 08___________________________

    NEW ASSOCIATE MEMBERSHIP


    Complete form and attached Direct Debit Mandate legibly using block capitals. Send both to the
    Honorary Secretary. Once notified of membership approval your mandate will be processed.
    PAYMENT
    st

    Annual Subscriptions are due on 1 January of the subscription year but payment by Direct Debit will be
    st
    deferred until 1 February of the year. The current subscription rates are detailed on www.iaem.ie. Please
    note that there is a significant discount if paying by Direct Debit.
    I hereby apply for Membership of the Irish Association for Emergency Medicine. I agree to abide by the
    Constitution and rules of the Association.
    SIGNED: ___________________________________

    DATE: ______________________________ Form 121113

    President:

    Secretary:

    Treasurer:

    Mr Mark Doyle FRCSI, FCEM

    Mr Cyrus Mobed FRCSI, DSM

    Mr Niall OConnor DCH, DObs, MRCGP, FRCSEd, FCEM

    Consultant in Emergency Medicine.

    Consultant in Emergency Medicine.

    Consultant in Emergency Medicine.

    Waterford Regional Hospital,

    South Tipperary General Hospital,

    Our Lady of Lourdes Hospital,

    Dunmore Road,

    Clonmel,

    Drogheda,

    Waterford,

    Co. Tipperary

    Co. Louth,

    Ireland.

    Ireland

    Ireland.

    Tel No: +353 51 842627

    Tel No: +353 52 6177987

    Tel No: +353 41 9874791

    Fax No: +353 51 848550

    Fax No: +353 52 6177149

    Fax No: +353 41 9874799

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