Firelands Ambulance Service
Membership Application
Membership in Firelands Ambulance Service is
Non-refundable.
Firelands Ambulance Service has the right to require proof of
conditions
of membership at any time and may withhold membership benefits
for any person for whom proof is not given.
THIS IS NOT AN APPLICATION FOR AN INSURANCE POLICY
Send completed form with $50.00 check or money
order
payable to : Firelands Ambulance Service,
25 James Street, New London, Ohio, 44851
____________________________________________________________
PLEASE PRINT
Head of Household
Name___________________________________________________Date of
Birth_________________
Address____________________________________________________________________________
City_________________________State______________________Zip__________________________
Phone__________________________________ Social Security
Number_________________________
List spouse and unmarried children under 18 or claimed as a dependent
________________ Date of
Birth________________ Social Security Number_________________
________________ Date of
Birth________________ Social Security Number_________________
________________ Date of
Birth________________ Social Security Number_________________
INSURANCE INFORMATION FOR HEAD OF HOUSEHOLD
Primary Insurance________________________________________
ID#_______________________
Address____________________________________________________________________________
Secondary Insurance______________________________________
ID#_______________________
Address____________________________________________________________________________
INSURANCE INFORMATION FOR SPOUSE & CHILDREN
Primary Insurance________________________________________
ID#_______________________
Address____________________________________________________________________________
Secondary Insurance______________________________________
ID#_______________________
Address____________________________________________________________________________
Signature of Applicant_________________________________________ Date___________________