Membership Application

Please provide the following contact information:

Organization
Street
City/State/Zip
Work Phone		FAX
E-mail		URL

Primary Contact

Name
Title		E-mail
Work Phone		Cell Phone

Other Contact:

Name
Title		E-mail
Work Phone		Cell Phone

 

I have read and agree to adhere to the Washington Ambulance Association's Code of Ethics and Standards of Conduct.

Signature		Date
Name		Title
No.vehicles licensed with Department of Health
Designated Voting Representative:
Name		Title
E-mail		Phone

Please print, sign, and mail to:

Washington Ambulance Association

3404 Moore St SE

Olympia WA 98501