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Emergency Shield Plus Membership Application
Primary applicant (First, Middle initial, Last)

First NameLast Name
Secondary applicant (First, Middle initial, Last)

First NameLast Name
Dependent 1 name (First, Middle initial, Last)

First NameLast Name
Dependent 2 name (First, Middle initial, Last)

First NameLast Name
Birth date

MonthDayYear
Birth date

MonthDayYear
Birth date

MonthDayYear
Birth date

MonthDayYear
Primary applicant
Secondary applicant
Dependent 1
Dependent 2
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Cell
Format: (000) 000-0000.
Other
Format: (000) 000-0000.
PO Box

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Type Of Membership
$50 Single monthly membership$67 Family monthly membership$550 Single annual membership$700 Family annual membership$2600 Single 5 year membership$3300 Family 5 year membership$4600 Single lifetime membership$5800 Family lifetime membership$99 one-time registration fee on all memberships
Date reoccuring Monthly
Date reoccuring Annually
By signing below: I hereby authorize Medical Air Services Association, Inc. ("COMPANY") and/or its subsidiaries, affiliates, or agents to initiate debits or to charge my account at the financial institution named above (the "BANK") in the amounts and with the frequency as ind indicated above, on the selected day of the the month/year, and every month/year thereafter. if any item is returned unpaid, I acknowledge that my BANK may debit or charge a returned check fee and/or overdraft fee, for which I shall bear sole responsibility.
I provide my signature expressly consenting to contact from COMPANY and/or its subsidiaries, affiliates, or agents to contact me regarding produ products or services via live, automated or prerecorded call, text, email, regular mail, or other electronic communication. I understand that I am not required to enter into this consent as a condition of purchase. I can revoke this consent by contacting MASA.
I consent to receiving certai certain electronic communications from MASA and/or its subsidiaries, affiliates, or agents and agree that any notices, agreements, disclosures, or other communications that MASA sends to me electronically will satisfy any legal communication requirements, including that those communications be in writing.
*This authorization remains in full force and effect and this membership will renew automatically upon expiration of the Member's initial membership term, and renew automatically upon expiration of each renewal term, for a term equal to the initial membership term and subject to any rate increases unless canceled in accordance with the terms and conditions of this membership. If you do not wish your membership to be automatically renewed, you may cancel this membership prior to the automatic renewal effective date by contacting MASA.
Applicant signature

Clear
Name (printed)
Date

MonthDayYear
Date
To secure your payment call this number 405-299-1216 or email ron@medtransport.net
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Emergency Shield Plus Membership Application

Type Of Membership