Join Now Membership Application Organizaton Trade Name (DBA):* Official Organizaton or Parent Company Name Organization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website Organization RepresentationPlease designate your primary and alternative representative who will be the point of contact and who may cast a vote on your organization's behalf Primary Representative* First Last Primary Rep Email* Primary Contact Phone*Alternate Representative First Last Alternate Rep Email Altrernate PhoneOrganizational StructureFormal Organization* Corporation City / Municipality ESD County Hopital Other (List Below) Tax Status* For Profit Non-Profit (501c3/4) Taxing Authority Other (List Below) Ownership Information: Corporations, Partnerships, Sole ProprietorshipsCorporate OwnershipNot ApplicablePrivate EquityPublicly TradedEmployee OwnedNational SubsidiaryOwner / Officer 1 First Last Title Location Primary business location Owner / Officer 2 First Last Title Location Primary business locationOwner / Officer 3 First Last Title Location Primary business locationService InformationNumber Of TDSHS Licensed Units*Service Level* MICU ALS BLS SCT Rotor Wing Fixed Wing Mark all that applyService Type* 911 Provider Emergency Non Emergency Scheduled Transports Mark all that applyStaff Type* Paramedic Intermediate / Advanced EMT Nurse Mark all that applyHours of Operation 24/7/365 Business Hours Modified Hours Dispatch Type* Internal PD / SO Regional Call Center Dispatch Phone*Direct Dial Number (Not 911)Service AreaPlease provide us with your primary response area(s) to include City, County or geographical locations.City(s) Served*County(s) Served*Geographic Area RAC Participation Please list the RACs your organization participates inState /National Response Agreements EMTF MOU FEMA Regional Mutual Aide Mark all that apply Δ
