MEMBERSHIP APPLICATION

(PLEASE PRINT LEGIBLY)

NAME:________________________________________________________________________________________________

ADDRESS:_____________________________________________________________________________________________

CITY, STATE, ZIP CODE:__________________________________________________________________________________

COUNTY:______________________________________________________________________________________________

EMAIL ADDRESS:______________________________________________________________________________________

PHONE NUMBER:____________________________________    BIRTHDAY:______________________________________

 IEMTA MEMBER REFERRING (If Applicable):________________________________________________________________

LEVEL OF TRAINING (Check all that apply):

____ First Responder          ____ Basic     ____Intermediate     ____ Paramedic

____ Dispatcher               ____ Nurse     ____ Educator          ____ System Coordinator

____ Dept/Squad Coordinator     ____ Physician     ____ Medical Director     ____ Other______________

EMS SERVICE (Primary):________________________________________________________________________________

EMS SYSTEM (Primary):________________________________________________________________________________

____ Volunteer               ____ Paid/POC

____ Check enclosed for dues     Amt. (Please circle):      1 yr/ $20.00     2yrs/ $30.00        3yrs/ $40.00

____ I wish a hard copy of the newsletter                         _____ I would like an electronic copy

Forward Applications to:

Augie Bamonti

733 Peoria

Chicago Heights, IL.   60411

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Date of Check/Cash:___________________________         Member Number:_____________________