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2008
MEMBERSHIP APPLICATION
ORGANIZATION:_________________________________________________________
CONTACT
PERSON:______________________________________________________
MAILING
ADDRESS:______________________________________________________
CITY:
_________________________ STATE: _______
ZIP CODE: ______________
BUSINESS
PHONE: ________________________ FAX:_________________________
EMAIL:________________________________________________________________
EMS
LICENSE NUMBER: _________ NUMBER OF
LICENSED AMBULANCES: _________
BASE
COUNTY: _____________________ TOTAL
POPULATION SERVED:__________
NUMBER
OF STATIONS: _____________ KAPA
REGION: ________________
TYPE
OF OWNERSHIP:
GOVERNMENT (
) PRIVATE
( )
HOSPITAL ( )
FIRE (
)
VOLUNTEER DISTRICT (
)
OTHER (
)___________________________________
DATE:
____________
( )
$ 150.00 Provider Annual
Dues
( )
$ 100.00 All Volunteer
Service
(
) $
100.00 Affiliate Member
Please make check payable to
"KAPA" and remit to: KAPA
Jamey Locke, Treasurer
Current
members may verify agency
3551 Coleman Road
information
on our web site.
Paducah, KY
42001
Revised
2008