INDIVIDUAL MEMBERSHIP APPLICATION
(Submit this form and pay by PayPal)

DUES: New Renewal Free (granted by MEMSA)                 DATE(MM/DD/YY):

Individual ($25) Individual Group Rate ($20) *

Group Membership #:    Expiration Date (MM/DD/YY):

* Individual-Group Rate applies ONLY when your employer's organizational membership has been paid.
  The group MEMSA number and expiration date must be listed.

Individual Associate ($30) Student ($15) (must include instructor name and school below)

Instructor     School:

Name:

M.D.    D.O.    EMT-B    EMT-P    RN    Student    FR    Other

Home Address:

City: County: State: Zip:

Employer: Work Phone:

Employer Address: Home Phone:

Employer City: State: Zip: Fax:

Email:

Beneficiary: Relationship:

A $1500 accidental death & dismemberment insurance is carried on each individual member.
Please indicate your beneficiary and his/her relationship to you.

ORGANIZATIONAL MEMBERSHIP APPLICATION
(Submit this form and pay by PayPal)

DUES: New Renewal                  DATE(MM/DD/YY):

Organization >400 patient contacts per year ($200)
Organization <400 patient contacts per year ($75)
Organization Associate ($300)
Training Entity ($75)
Emergency Medical Response Agency (EMRA) ($75)

Name of Organization:

Application Prepared By: Title:

Business Address:

City: County: State: Zip:

Work Phone: Work Fax:

Email:

NOTE: Organizational memberships include up to three (3) voting representatives. Please indicate below:

Name: Title:

Home Phone:

Home Address:

City: County: State: Zip:

Soc. Sec. #: Email:

**Beneficiary: Relationship:

Name: Title:

Home Phone:

Home Address:

City: County: State: Zip:

Soc. Sec. #: Email:

**Beneficiary: Relationship:

Name: Title:

Home Phone:

Home Address:

City: County: State: Zip:

Soc. Sec. #: Email:

**Beneficiary: Relationship:

** A $1500 accidental death & dismemberment insurance is carried on each individual member.
    Please indicate your beneficiary and his/her relationship to you.