Event Booking

BALATI EMS, LLC Event Medical Booking Form
Please complete each item on this form and click submit. Form must be received to secure a reservation. This form must be filled out completely to be accepted. The event shall not be confirmed until a signed agreement is executed by Balati EMS, LLC.
EVENT INFORMATION
Organization*
Event Production Manager Full Name (must be an individual)*

First NameMiddle NameLast NameSuffix
Cell Phone Number*

Area CodePhone Number
Event Production Manager Email*
Venue Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Event Venue Point of Contact *

First NameLast Name
Event Venue Point of Contact Email*
example@example.com
Cell-Phone*

Area CodePhone Number
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Event Contact Person (if different from Event Production Manager)
Event Contact Person Phone Number

Area CodePhone Number
Event Contact Person Email
example@example.com
I prefer to communicate by*

EmailPhoneUS Mail

Type of Charge

Weekdays

Weekends

Holidays

Event Medical-

Flat Rate Per Event

$300

$400

$440

Day 1 (All Fields Marked With An * Are Required)
Type of Activity*
Time In*

MonthDayYearHourMinutesAM/PM Option
Activity/Event Begins*

MonthDayYearHourMinutesAM/PM Option
Time Out*

MonthDayYearHourMinutesAM/PM Option
Day 2
Type of Activity
Time In

MonthDayYearHourMinutesAM/PM Option
Activity/Event Begins

MonthDayYearHourMinutesAM/PM Option
Time Out

MonthDayYearHourMinutesAM/PM Option
Day 3
Type of Activity
Time In

MonthDayYearHourMinutesAM/PM Option
Activity/Event Begins

MonthDayYearHourMinutesAM/PM Option
Time Out

MonthDayYearHourMinutesAM/PM Option
Additional Days
Include Type of Activity, Time In, Activity Start Time, and Time out for each day.
An estimation of event medical fees will be provided upon confirmation of receipt of this application. All additional equipment and additional time shall be added to this amount and invoiced to the event management.

APPLICATION SUBMITTAL
An estimation of event medical fees will be provided upon confirmation of receipt of this application. All additional equipment and additional time shall be added to this amount and invoiced to the event production management.
Comments
Name of Person Filling Out Form

First NameLast Name
By clicking submit, you acknowledge and agree to the above terms and conditions.
Should be Empty:

BALATI EMS, LLC Event Medical Booking Form