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Membership Application 2023/24
Alabama Association of Ambulance Services
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* Indicates required question
Email
*
Your email
Agency Name
*
Your answer
Mailing Address
*
Your answer
Physical Address
Your answer
Contact Name
*
Your answer
Contact Phone #
*
Your answer
Contact email
*
Your answer
County / Service Area
*
Please list all Counties served by your service, if out of the State of Alabama, please include State with County.
Your answer
Select provider classification
*
ALS only
BLS only
ALS and BLS
non-profit / government
Private for profit
Other:
Required
Do you bill for service?
*
Yes
No
Select Member Due's classification
*
Membership dues are based on # of transport vehicles in fleet
Choose
1 - 9 transport vehicles - $250.00 annually
10 - 19 transport vehicles - $750.00 annually
20-35 transport vehicles - $1125.00
36+ transport vehicles - $2250.00
Associate Member - $250.00
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