Member Application

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Contact Information
First Name: *   MI 
Last Name: *
Suffix (ex: Jr.):
Prefix: *
Job Title:
Date of Birth: *
Referred By:
Maiden Name:
Primary Email: *
Primary phone:    Ext:   
Primary Address Type: *
Country: *
Attention Line:
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City: *
Postal Code: *
No External Mail:

Web Credentials

Web Credentials help provide you with access to exclusive member content online, and also helps simplify event registration and order processing.

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Please contact the SEMPA Member Care Center at membership@sempa.org or call 877-297-7594.

Membership Categories

Please select one of the Membership Categories below:

 Associate (1 year membership - $180 / 2 year membership - $340):  An individual who is not eligible to be a Fellow member but has an interest in the field of emergency medicine physician assistants. Associate members shall be entitled to participate in all SEMPA activities, committees, and petitions to the Board but are not eligible for election to the Board of Directors. Associate members shall have no voting rights.

Membership Term

Please select one of the following:

Senior Fellow Application

To qualify for Senior Fellow, you must have 10 or more continuous years of membership in SEMPA.
By completing this application you certify that you qualify for this status.

Date became a SEMPA Member:
NCCPA Certification
Certification Date:
Expiration Date:
ReCertification Date:

Medical License
License Type Code:
State Province:
License Date:
License Number:
Has this License ever been revoked or suspended?

If your are applying for a Student, Resident or Fellow membership, you must provide your graduation or expected graduation date(s).

PA Program
Select PA Program
Graduation or Expected Graduation Date
Residency / PostGraduate Program
Select Post Graduate Program
Graduation or Expected Graduation Date

Select Fellowship:
Begin Date:
End Date:
Emergency Medicine Career Information
Primary Practice Location: *
Year began Emergency Medicine Career:
NPI Number

Military Tour
Branch of Military:
Military Rank:
Tour Begin Date:
Tour End Date:

Hospitals/Urgent Care

Add Hospital
Country: *
State Province:

Can't find your Hospital/Urgent Care? Please select 'Manually enter Hospital/UrgentCare information..' from the Hospitals list above to send a request to the SEMPA Member Care Center to add a new hospital/Urgent Care.

Physician Group
Physician Group:
AAPA Membership
Are you an AAPA member?
AAPA Number:
What is your primary work setting?

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Enter the code in the “Promo Code” box to activate the promotion or special offer. After your order is complete, you will receive an email with instructions on redeeming your promotion or special offer. Please note that promotions and special offers are a final sale -- there are no refunds or exchanges. Offers and promotions cannot be combined with any other offer or promotion, or applied to previous purchases.

NEMPAC Contribution
The National Emergency Medicine Political Action Committee of ACEP collects personal donations from members for contributing money to Federal candidates.
Contributions are voluntary and are not required for ACEP membership.
The contribution requested is only a suggested amount. ACEP will not look upon any member with favor or disfavor by reason of the amount of their contribution or their decision not to contribute.
NEMPAC contributions which are received on a corporate check will be used to pay for the educational programs of NEMPAC and other activities permissible under Federal law.

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