CoROM Membership Application

Name*

First Middle Last

Address*

This will be used as mailing address for your certificate.

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email address:*

Please upload supporting documentation here:*

Drop files here or

Max. file size: 128 MB, Max. files: 10.

We need to see proof that you are currently registered as a healthcare practitioner such as an EMT, Corpsman, 68W, 18D, nurse, paramedic or physician. If you have an equivalent medical qualification please upload that and we will be happy to take a look and let you know if we can accept it.

Choose you desired level of CoROM membership:*

Member €80
Lifetime Member €950

Are you registering as a member of a group? If so, please tell us what group or company you are part of.

Any questions or comments?

Privacy*

By using this form you agree with the storage and handling of your data by this website. *

What happens next?

We will process your application in December. If you are invited to join the Council of Members for 2021, we will send you a link to pay your membership fees. Your Certificate of Membership will be posted to you in early 2021.