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Membership Subscription Application and Donation Form

• Please complete the form below along with your payment and/or donation information and press the 'Submit' button.
• For more information about the membership subscription program, please contact:
       East Pennsboro Ambulance Service business office at (717) 732-5552

Select a Membership and/or Donation

• If you are applying for a Membership Subscription, please indicate where you reside from the drop down list.
• If you want to make a donation only, please select "I would like to make a donation only."
• If you choose a membership, you can include an additional donation amount.
• The membership subscription fee of $80.00 covers one household location for up to 8 people.

Required fields are marked with the * (asterisk symbol). For security reasons, if you navigate away from this page before submitting your information, you will need to complete the form again.

Address of Membership Household Residence

Street Address 1

   Apt/Suite/Other    Apt/Suite/Other #

   PO Box #

   Street Address 2

City State   *  Zip Code

Phone Number

Household Names To Be Covered

• Up to 8 names for a single household can be covered in a membership.
• If a membership is being completed, Name 1 is required. Additional names are optional.
• For each name listed, a first and last name are required at a minimum.
• Please provide the legal name of each person listed.
• If the location is a business, use the word business as the first name and the business name as the last name.

 

Name 1  Mr/Mrs/Ms  First Name  Middle Initial  Last Name  Suffix

   Name 2        

   Name 3        

   Name 4        

   Name 5        

   Name 6        

   Name 7        

   Name 8        

Payment and/or Donation Amount

Membership Dues $

   Donation Amount $

   Total Amount Due $

Credit Card Payment Information

* Credit Card Type
* Card Number
* Expiration
MM YY
* Name on Credit Card
* Card Security Code
Where is your card security code?

The card security code is a 3 or 4 digit
number on the back or front of your card.
The code is also known as a CVV, CVV2,
CID or CVC2 code.

BackOfCreditCard AmexFrontCard

Click Here for Additional Information on the Card Security Code

Billing Address
Street
Apt., Suite, etc.
City State Zip
Cardholder's Phone
Cardholder's Email Address
   

* To ensure security, please check the box below next to the phrase "I'm not a robot" to verify that you are an actual human submitting this information.

Please review your information carefully. Your payment information will be processed immediately after clicking the 'Submit' button. All sales are final.

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