2021 - 2022 Membership Subscription Application

• Please complete the form below along with your payment information and press the 'Submit' button.
• For more information about the membership subscription program, please contact:
Upper Merion Township EMS business office at (610) 265-3232

Select a Membership

• This membership is for the period August 1, 2021 - July 31, 2022
• Please indicate the type of membership from the drop down list.
• The membership types and subscriptions are as follows:

Level	Description	Due
Senior Individual	Covers 1 adult (60+)	$50.00
Senior Family	Covers 2 adults (60+)	$75.00
Individual	Covers 1 adult	$75.00
Family	Covers 2+ Individuals	$125.00

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.

* Membership

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 name, last name, and date of birth is 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 * DOB

Name 2

Name 3

Name 4

Name 5

Name 6

Name 7

Name 8

Payment Amount

* Membership Dues $

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.

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.