Sign up for Agency Membership 

Additional Info

This application must be completed by the Agency Representative/Contact only. Upon receipt, NAEMT will provide your Agency ID number and instructions on how to submit information for your individual Agency Members.
Agency Name (Name of EMS Service)
Agency Mailing Address:
City
State
Zip
Country
Agency Website
Agency Primary Contact Name
Primary Contact Phone
Primary Contact Fax
Primary Contact Email
Referral Information
NAEMT Member
NAEMT Affiliate Organization
Other:
Tell Us About Your EMS Service
Area



Size



Type

Payment Information
Agency Membership Annual Dues: $400 for up to 10 EMS professionals and $35 for each additional Agency Member.
Additional discount available for agencies of 50 or more.
Number of Agency Members
Total Due: $
Name on card:  
Credit Card Type:
Card Number:  
Expiration: /
Cvv2 Number:
Billing Address
City
State
Zip