North Carolina Association of Rescue & EMS, Inc.

P.O. Box 1914
Goldsboro, North Carolina 27533-1914
Telephone: 919/736-0506 Fax: 919/736-7759 E-Mail: ncarems@ncarems.org

MEMBERSHIP APPLICATION

NAME OF UNIT: E-MAIL:

ADDRESS: (Mailing)

STREET: COUNTY:

CITY: STATE: ZIP:

BASE PHONE: FAX: COMMUNICATION CENTER:

SERVICES PROVIDED:

FIRE MEDICAL RESPONDER EMS (AMBULANCE RESCUE)
LIGHT RESCUE MEDIUM RESCUE HEAVY RESCUE
SPECIALTY RESCUE* SPECIFY TYPE*

** CHECK ALL THAT APPLY **

SQUAD CAPTAIN/CHIEF: PAGER #:

E-MAIL:

ADDRESS:
CITY: STATE: ZIP:

DAYTIME PHONE # NIGHTTIME PHONE # CELL PHONE #

SQUAD SECRETARY:

ADDRESS:
CITY: STATE: ZIP:

DAYTIME PHONE # NIGHTTIME PHONE # CELL PHONE #

E-MAIL:

NUMBER OF MEMBERS IN SQUAD: DATE SQUAD WAS ORGANIZED:

ARE YOUR SQUAD MEMBERS PAID    VOLUNTEER    BOTH ?
WILL YOUR SQUAD ANSWER CALLS OUTSIDE YOUR AREA? YES    NO

AREA YOUR SQUAD COVERS:

LIST OF EQUIPMENT: EXPLAIN, IN DETAIL, ANY SPECIAL EQUIPMENT:

DO YOU TRANSPORT VICTIMS? YES    NO
DO YOU FURNISH AMBULANCE SERVICE? YES    NO