Annual Membership Application

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Annual Membership Application

Membership into the NMEMTA is open to any New Mexico emergency medical provider who holds a current license as an Emergency Medical Dispatcher, Emergency Medical Responder, Emergency Medical Technician, Advanced Emergency Medical Technician, Paramedic, or Physician. Applicants must not have a felony conviction or unresolved license suspension.

Membership Fee Due = $15.00 annually

A pay link can be sent via email or a check can be mailed. Please make check payable to NMEMTA and mail to:

NMEMTA, P.O. Box 861, Grants, NM 87020

Email *

Today's Date *

YYYY

Last Name *

First Name *

NM EMS Level *

EMD

EMR/First Responder

EMT

AEMT/EMT-Intermediate

Paramedic

Other:

NM EMS Licensure Number

Department/Agency (if applicable) *

Mailing Address *

City *

State *

Zip Code *

Contact Phone Number *

Email Address *

Payment Option *

Credit Card (link will be send to your email)

Mailed Check or Cash (use address listed at the top of the page)

A copy of your responses will be emailed to the address you provided.

Submit

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