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SaveAir -- Membership Application Form

Type of Membership Requested:

 New      Renewal      Gift
  One Year $45              Two Years $85

Name of Insured _________________________________________________________

DOB ___________________________________________________________________

SSN ___________________________________________________________________

Address ________________________________________________________________

City _______________________________ 

State ______________________________  ZIP _______________________

Phone _____________________________

Insured Household Members:
                First Name                    Last Name                    SSN                    DO

                _______________________________________________________

                _______________________________________________________

                _______________________________________________________
                If there are additional insured household members, include separate page.

Insurance Carrier Name ____________________________________________

                Group Number ________________________

                ID # _________________________________

                Phone ______________________________

You may pay by check, money order, Visa or MasterCard.

Credit Card # __________________________________

             CVV  ____________    Expiration Date ________________

Signature __________________________________

Date __________________________________
  
Membership begins 14 days after receipt of funds and expires after date printed on membership card.  Make check payable to:  American Medflight, Inc.  Mail this form along with payment and copy of each member's insurance card (front and back) to:  American Medflight, Inc., P.O. Box 10166, Reno, NV  89510-0166.


AMERICAN  MEDFLIGHT AIR AMBULANCE  © 2012 l PRIVACY POLICY