ORGANIZATION__________________________________________________

ADDRESS_______________________________________________________

CITY__________________________________________________________

COUNTY/CITY SERVED____________________________________________

PHONE_________________________________________________________

CONTACT PERSON________________________________________________

E-MAIL________________________________________________________

NUMBER OF VEHICLES____________________________________________

NUMBER OF STATIONS____________________________________________

TYPE OF SERVICE_______________________________________________

DATE__________________________________________________________

( ) $25.00 Annual Dues ( ) $10.00 Annual Dues Volunteer Service

( ) New Applicant ( ) Renewal

Make Checks To: Eastern Kentucky Ambulance Providers Association

Send Checks To: Eastern Kentucky Ambulance Providers Association Allen's Ambulance Service Attn: Michael Mason P.O. Box 83 Main Street Boonveille, Kentucky 41314