new member application - Professional Ambulance Association of ...

NEW MEMBER APPLICATION(This form uses Microsoft Word fill-in. Type information in the gray box. The field will expand as needed.The PDF version is a simple print and write-in form.)ORGANIZATIONOrganization NameAddressAddress 2CityStateZIPTelephoneFAXWebsite URLCONTACTPrimary (Voting) Contact NameJob TitleDirect TelephoneCellularEmailDEMOGRAPHICSService Level of License: Basic IT I Paramedic Critical Care P N/AOwnership Type: For Profit Nonprofit GovernmentNumber of EmployeesNote: Email employee roster to Dan Williams at dan@paaw.us. (Minimum requirement Word or Excel: (tabdelineated columns) First Name, Last Name, Email Address). Employee emails are not shared with third parties.Offer Department Ride Alongs Yes No Restrictions, if anyInformation Unique to Your ServicePURPOSEPrimary reason you are joining PAAW?What benefits or services are most important to you?

Voting Member (ambulance service or group)MEMBER DUES FORMULAMember dues are prorated the first year, since all members renew January 1 of next year. Dues are also basedon the number of ambulance runs per year.Section One: Select the number of ambulance runs completed last year (check appropriate box):Out-of-State ($400) 2,501 to 5,000 ($750) 12,501 to 15,000 ($2,500)0 to 500 ($400) 5,001 to 7,500 ($1,000) 15,001 plus ($4,000)501 to 1,000 ($400) 7,501 to 10,000 ($1,500)1,001 to 2,500 ($400) 10,001 to 12,500 ($2,500)Section Two: Select the month your membership will start (check appropriate box):12 11 10 9 8 7 6 5 4 3 2 1Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecSectionYourMember Dues Worksheet (Pro-rated)Three:InformationExampleLine 1 Insert annual dues total from Section One $ $750.00Line 2 Divide Line 1 by 12 months, enter on Line 3 12 12Line 3 Enter answer for Lines 1 and 2 $ $62.50Line 4 Insert month number from Section Two 10 (Mar)Line 5 Line 3 times Line 4 equals $ $625.00Line 6 Less $100 new member discount $ -100.00 Less $100.00Line 7 Total Member Dues for Current Year $ $525.00PAAW pays on behalf of each member a $75 annual fee to the North Central EMS Cooperative. There isnothing that you need to do, except enjoy the benefits of North America’s largest EMS group buying program.Three-Month Trial MembershipCheck here if selecting a three-month trial membership for $75.00. Following three-months ofmembership, the total listed in Line 7, less $75.00, will be invoiced, unless otherwise notified.Direct member questions to: Dan Williams, Executive Director, email dan@paaw.usMethod of Payment & Submitting New Application:Bill Me (Payable within 30-days of invoice date). Fax to Jack Hill at fax 920-727-3033 or save documentand email to admin@paaw.us.Authorization to bill (insert name same as signature):Today’s DateCheck enclosed, process immediately. Write check or issue payment payable to “PAAW”.Mail completed membership application and payment to:Professional Ambulance Association of WisconsinAttn: Jack Hill, Treasurer1055 Wittmann DriveMenasha, WI 54952-3606