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					CALIFORNIA RESCUE AND PARAMEDIC ASSOCIATION
                                                 MEMBERSHIP APPLICATION
By joining the CRPA, you will help support efforts to work toward improving the quality of emergency medical
services in the State of California! Since 1982 the CRPA has represented the professional interests of the
prehospital care provider in California. Your participation is vital to our growth, not only as an Association but our
profession overall.

Name:

Job Title:

Home Address:

City, State, Zip Code:

Home Phone:                   (      )                                            Work: (         )

Email Address (required):
As a member, you will receive a quarterly electronic newsletter detailing the regulatory and legislative issues involving EMS.

Employer/Provider:

Other Associations:

County(ies) of Licensure/Accreditation:
1 year membership is limited to pre-hospital personnel:
Mail to: CRPA – Membership, 657 Mission St, Ste 302, San Francisco, CA 94105
or you can fill out the form and fax to 415-543-0415 or email to registrar2@sfparamedics.org

              Active Membership $20
              Physician Memberships $20
              EMS student: $10
              Associate Membership $20
              Corporate/Vendor Membership call 415.543.1161 x305

          Active member check:      EMT-1       EMT-II       Paramedic       MICN       Physcian
          For membership you must provide a License/Certificate Number:
          Membership expires for 1 year from joining date, either May or November, whichever is further.

PAYMENT INFORMATION
  CASH       CHECK if paying by cash come to the SFPA office or mail check out to CRPA and mail to CRPA
Membership, 657 Mission St, Ste 302, San Francisco, CA 94105

     CREDIT CARD (Visa or MC) Card Number:

Expiration MM/YY:                                  Signature:

Please see our website for more information: www.sfparamedics.org/crpa


                                                             CRPA USE ONLY

PAYMENT MADE____________ COMPUTER ENTRY ____________ MEMBERSHIP CARD__________
DATE MAILED ___________ EXPIRATION    ___________

				
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