Membership Form Name* First Last Address* Street/Mailing Address Address Continued City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Select Membership Type* Single Membership ($75) Family Membership ($100) Business Membership ($250) Household SizePlease enter the names of the members of your household. If you have more than 5 members in your household, please contact us by email admin@yorkambulance.com 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 membershipSelect Amount$25$50$100$250$500$1000Total $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 ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name SignatureCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ