2023 Membership Application Form and Roster

2023 NVFC Membership Roster
Department Information
Department Name
Department Primary Contact*

First NameLast Name
Primary Contact Email*
example@example.com
Department Mailing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Department Phone Number

Area CodePhone Number
Member Roster

Enter the information below for each Individual member. Leave address fields blank if the member wishes to use the department's mailing address. Please indicate if the individual would like to be a part of the complimentary EMS/Rescue Section (https://www.nvfc.org/ems-rescue-section/). If you have more than 30 members or don't wish to type in each member'sinformation here, please use the Upload Roster button below. After you're done, update the quantity of members and submit the payment on the bottom of the form.
Name #1

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #2

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #3

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #4

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #5

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #6

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #7

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #8

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #9

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #10

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #11

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #12

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #13

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #14

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #15

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #16

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #17

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #18

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #19

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #20

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #21

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #22

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #23

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #24

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #25

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #26

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #27

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #28

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #29

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Name #30

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
EMS/Rescue Section

YesNo
Upload Roster

Browse Files

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Please indicate method of payment*

Credit Card (enter card below)Check (mail check payable to NVFC; 712 H St, NE, Suite 1478; Washington, DC 20002). Skip to "Submit Application" button below.

Membership

Individual Membership$21.00

Quantity

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty: