Service/Corporate Membership Information

Name of organization as it should appear on the list of services published by the Wisconsin EMS Association

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Service Telephone Number ____________________________ Fax Number _________________________________

Service Web Address ________________________________ Service E-Mail _______________________________

Service contact person __________________________________________________________________________

Contact’s Telephone number __________________________ Contact’s E-Mail ______________________________

Service Mailing Address ______________________________ City __________________________ Zip _________

Service type: Volunteer   Paid on Call   Full time paid staff Combination of paid & volunteer staff 

Service level: First Responder    EMT-Basic    EMT-Basic    EMT-I Technician    EMT-I    EMT-P 

What does the service see as its biggest challenge for 2008? ________________________________________________

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What additional products or services could the Wisconsin EMS Association provide to help your service?

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Return this page along with your list of members and check.. Feel free to use the back side or a separate page to make any additional comments. If you have other information about your service, such as newsletters, community mailings, annual reports, special projects, or data collection results, please include it with your membership application as well. The information you provide will be kept confidential by the Wisconsin EMS Association.

Wisconsin EMS Association  -  21332 7 Mile Road  -  Franksville, WI 53126-9769