Membership Plans 2024 Membership Step 1 of 5 - Membership Plans 20% Membership Plans* Single Membership (1 person) Household Membership (2 or more in same household) Corporate (1-15 employees) Corporate (16+ Employees) Total $0.00 Your Name* First Last Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Name First Last Birthday Name First Last Birthday Name First Last Birthday Name First Last Birthday Name First Last Birthday The membership program is applicable only to medically necessary EMERGENCY ambulance transportation to any of the surrounding acute care hospitals in our area, nonmembers will be obligated to pay all payments, co-payments, and deductibles as required by their health insurance plan. Currently the basic rates can start from $900. Subscriptions will not be retroactive or pro-rated. Lift assist service is not covered in a membership. Members will receive a discounted rate of $25 (non members $50) MVEMS, Inc. reserves the right to collect and receive any available third party (insurance) billing monies from its subscribers. Subscribers agree to forward any insurance payments received for services rendered by MVEMS or its agents to MVEMS.I agree I have read the statement above and agree to the terms and conditions.* I agree Digital Signature* Date* MM slash DD slash YYYY Would you like to donate to the MVEMS building campaign? Yes No Donation Amount $5 Donation $10 Donation $25 Donation $50 Donation Other Other Total Due $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name