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12

|

M

i s s o u r i

EMS C

o n n e c t i o n

FALL 2015

Missouri Emergency Medical Services Association

INDIVIDUAL MEMBERSHIP APPLICATION

____New ____Renewal

DATE_________________

____ Individual $25

____ Individual Group Rate

*

$20 Employer MEMSA Member #____________Exp. Date__________

____ Individual Associate $30

____ Student $15 (application must be signed by instructor)

Instructor________________________________School____________________________

*

Individual-Group Rate applies

ONLY

when your employer’s organizational membership has been paid. The group MEMSA number and

expiration date must be listed.

Name

__________________________________________Soc. Sec. #_____________________County________

____M.D. ____D.O. ____EMT-B ____EMT-P ____RN ____Student If Other, specify_________

Home Address________________________________City_______________________State______Zip________

Employer__________________________________________________Work Ph__________________________

Street Address______________________________________________Home Ph_______________________

City_______________________State_______Zip_______Fax_________

Email

___________________________

Beneficiary______________________________________________Relationship_________________________

A $10,000 accidental death & dismemberment insurance is carried on each individual member. Please indicate above your beneficiary and

his/her relationship to you.

SS# is optional --needed to pay benefit to beneficiary

.

ORGANIZATIONAL MEMBERSHIP APPLICATION

____New ____Renewal

DATE_________________

____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____________State_______Zip________

Work Ph_____________Fax________________

Email

_______________________________________

NOTE

:

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

SS# is optional --needed to pay benefit to beneficiary

.

Name

__________________________________Title_________________Home Ph_______________

Home Address____________________________City_______________State_________Zip________

Soc. Sec.#___________________

Email

_________________________________________________

Beneficiary_________________________________Relationship______________________________

Name

__________________________________Title_________________Home Ph_______________

Home Address____________________________City_______________State_________Zip________

Soc. Sec.#____________________

Email

_________________________________________________

Beneficiary_________________________________Relationship______________________________

Name

__________________________________Title_________________Home Ph_______________

Home Address____________________________City_______________State_________Zip________

Soc. Sec.#___________________

Email

_________________________________________________

Beneficiary_________________________________Relationship______________________________

PAYMENT:

Amt. Enclosed__________Check #____________

Credit Card: VISA___

MC______

For Office Use Only:

Card#______________________________________________

Expiration date_______________________________________

Date Rc’d. _____________

Name on Card________________________________________

Renewal Date___________

Signature____________________________________________

Amount Rc’d.___________

Check#________________

Mbsp pck mail on________

Mail to: MEMSA P. O. Box 195 Breckenridge, MO 64625

Fax (credit card payment only) 573-431-7014 or email to

memsa@memsa.org

or join on-line

www.memsa.org

Please provide email

addresses. Much of our

correspondence is electronic.