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ETMC Emergency Services

EMS Membership Application


Step 1 - Member Information
[ Head of Household Information ]
Sex:
M:  F:
SSN:
*
Date of Birth(MM/DD/YYYY):
*
First:
MI:  
Last:
*
Address:
*
City:
*
State
Zip:
*
County:
*
Email:
*
Phone:
*



Are you Currently on Medicare?:
N  
Are you Currently a Nursing Home Resident?:
Y  N  
Would you like to include your spouse on the membership?:
Y  N  

[ Spouse Information ]
Sex:  
M:  F:
SSN:
*
Date of Birth(MM/DD/YYYY):
*
First:
MI:  
Last:
*
Are they Currently on Medicare?:
N  
Are they Currently a Nursing Home Resident?:
Y  N  
[ Additional Household Members ] (Children under 21 unless in college)

Add Additional Members: