Membership Form – York Ambulance

Name*
First Last
Address*
Street/Mailing Address Address Continued City State ZIP Code
Phone*
Email*
Select Membership Type*
- Single Membership ($100)
- Family Membership ($150)
- Business Membership ($300)
Household Size
Please enter the names of the members of your household. If you have more than 5 members in your household, please contact us by email [email protected]
- 2
- 3
- 4
- 5
Family Member 2 Name
First Last
Family Member 3 Name
First Last
Family Member 4 Name
First Last
Family Member 5 Name
First Last
Business's Name
Number of Employees
Additional donation you would like to add to your membership
Total
$0.00
Pay by
- Credit Card
- Check
PLEASE MAKE CHECKS PAYABLE TO: YORK AMBULANCE

MEMBERSHIP AGREEMENTS ARE IN EFFECT ON DATE OF RECEIPT AND WILL EXPIRE ON AN ANNUAL BASIS ONE YEAR FROM EFFECTIVE DATE.
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Signature
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Email
This field is for validation purposes and should be left unchanged.