Affiliate Advisory Council Representative Form

Affiliate Advisory Council Representative Contact Information

Hello. We want to know more about your organization leaders so we can streamline our communications. Please provide the following using the text fields below:

Information for your President and Executive Director (for our records only).
Information for the two representatives (if different from above) who will act as official contacts for the AAC and receive all communications on behalf of your association.

If you have any questions, please contact NAEMT via email (membership@naemt.org) or phone (800-346-2368). Thank you!

Association Information

Association Name:*

Association Address: *

Association City, State, Zip: *

Association Country: *

Association Phone Number: *

Association Website:

Executive Director Information

Executive Director Name:

Executive Director Email:

President Information

President's Name: *

Email Address: *

Phone Number: *

Term Dates: *

Appointed Representative #1

Appointed Representative #1 Name: *

Email Address: *

Phone Number: *

Appointed Representative #2

Appointed Representative #2 Name: *

Email Address: *

Phone Number: *

Form Completed By

Completed by: *

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Affiliate Advisory Council Representative Information

Affiliate Advisory Council Representative Information

Association Information

Executive Director Information

President Information

Appointed Representative #1

Appointed Representative #2

Form Completed By