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VIRGINIA ASSOCIATION OF GOVERNMENTAL
EMERGENCY MEDICAL SERVICE ADMINISTRATORS
623 North Avenue, Charlottesville, VA 22091
Phone: 434-531-3698 FAX 434-295-9302
Email:
vagemsa1@vagemsa.org
EIN # 54-1583252
Membership Application
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Agency:
_______________________________________ |
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Address:
______________________________________
City: ________________________________State:
____ Zip: __________ |
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Phone:
( ) |
FAX:
( ) |
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Agency Website: |
ANNUAL AGENCY DUES
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Primary Delegate:
Alternate: |
$75.00
included |
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Additional Memberships ($15.00 each)
1.
2.
3.
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$
$
$ |
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Total Remittance Due |
$ |
Please review the attached membership information and
provide supporting comments for the level of membership
being requested.
Type of membership requesting (please check one):
Active Associate
Supporting comments (attach additional sheet if
necessary):
VAGEMSA
Membership Categories
BOARD OF DIRECTORS – The Board of Directors of
the Association shall have voting authority and consist
of one appointed representative and one alternate from
each of the organizations represented.
ADDITIONAL AGENCY MEMBERS
– Additional agency members may be appointed by the
organization represented. Additional agency members do
not have voting privileges, unless acting in the absence
of their primary and alternate agency member.
ASSOCIATE MEMBERS: The Association may bestow an
ASSOCIATE MEMBERSHIP upon an organization or an
individual serving in a coordination or management
position of an EMS organization, but who does not
otherwise qualify for an active member status.
Associate Members shall be subject to payment of dues
but will not have voting privileges and may be removed
at any time at the discretion of the Board of Directors.
Associate Members must be recommended to the Board of
Directors at least thirty (30) days prior to a scheduled
meeting and approved by at least 2/3 of the quorum of
members.
Letter of Interest
Please complete the following information and mail or
email to VAGEMSA at the address provided above.
Organization:
Contact Person:
Mailing Address:
Email Address:
Phone and FAX Numbers:
_____Yes, my agency is interested in joining. Our $75.00
membership fee will follow with an invoice.
_____Please bill my agency for membership at the above
address.
_____I am interested in your $15.00 individual
membership, payment to follow with an invoice.
Change of Status Notification
_____Please remove the following name(s) from your
mail/email listing.
1. 4.
2. 5.
3. 6.
VAGEMSA Application – Revised January 2009
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