MEMBERSHIP
|
MEMBERSHIP |
| Name:___________________________________________________________________ |
| Address:_________________________________________________________________ |
| City, State, Zip:___________________________________________________________ |
| Professional Designation: (If MD, specialty):___________________________________ |
| Email Address:____________________________________________________________ |
| Business Phone:___________________________________________________________ |
| Home Phone:_____________________________________________________________ |
| Fax:_____________________________________________________________________ |
Date Application Completed: ___________________ |
(Circle one)
Renewal New Member Donation |
Donations in addition to membership would be appreciated! |
| Membership Fee: $__________ |
| (Member 50.00, Organization 100.00, Large Organization 250.00) |
| Donation: $__________ |
| Total: $_____________ |
The EMSA News is available on the website. |
Would you like to be mailed a hard copy
of the News when published? Yes No (Circle) |
Letter of receipt needed? Yes No (Circle)
|