Name of Business: ___________________________________________________________
(or individual if applying for individual membership)
Business Phone: (____) ___________________ Fax: (_____) _______________________
Mailing Address (if different): __________________________________________________
City: _______________________________ State: ______Zip: ________________________
Name of Person(s) representing organization to GHEMSC, Inc.:
Name: _____________________________ Email Address: ___________________________
_______$25 Individual: (Including Physicians, Nurses, EMS personnel, Consumer Advocates,
or any other natural person NOT representing an Entity or Organization)
_________$100 Volunteer Organization (meeting the EMS Volunteer Provider Criteria
established by the Texas Department of Health EMS rules)
_________$100 Public Organization (State, County or Municipal Operated Fire Dept.
or EMS Service, Etc.)
_________$100 Non-Profit Institution: (Hospital, Community or State Supported
Colleges, Etc.)
_______$200 For-Profit Institution: (Private Hospital, Trade School)
_______$100 Commercial or Industrial EMS Provider: (Operating 5 trucks or fewer)
_______$200 Commercial or Industrial EMS provider: (Operating more than 5 Trucks)
_______$200 Vendor: (Suppliers of EMS Equipment, Suppliers, or Services Ins. Etc.)
* - Prorated quarterly in initial year of membership. Please note application fee is Non-Refundable.
Amount Enclosed: ____________
Please Make Checks Payable To: For Questions Membership Contact:
Greater Houston EMS Council Rafael Galvan 281-831-0433
Mail to Address above