Ambu-Care Signup/Renew Your Membership Form

I am a:

Renewing memberNew member

Your Name*

First NameLast Name

Member Number

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Date of Birth*

Month/Date/Year

Choose one*

MaleFemale

Social Security Number*

Please fill in last four numbers of your SSN

Social Security Number *

Please fill in last four numbers of your SSN

If you have a spouse and would like to enroll him/her as well, please fill out the following information (spouse is included in the $85 payment).

Spouse Name

First NameLast Name

Spouse Member Number

Date of Birth

Month/Date/Year

Choose one

MaleFemale

Social Security Number

Please fill in last four numbers of your SSN

Social Security Number

Please fill in last four numbers of your SSN

If you have dependents (dependents are claimed on your taxes) and would like to enroll them, please fill out the following information. Please use the following format for each dependent you wish to enroll:

1.FULL NAME, DATE OF BIRTH, MALE/FEMALE, SOCIAL SECURITY NUMBER, INSURANCE CO., POLICY#, MEDICARE#
2.FULL NAME, DATE OF BIRTH, MALE/FEMALE, SOCIAL SECURITY NUMBER, INSURANCE CO., POLICY#, MEDICARE#

You may enter as many dependents as you would like to enroll.

Children to Enroll

E-mail*

Payment*

Michigan Ambu-Care Membership$85.00

Credit Card

First Name

Last Name

Credit Card Number

3 Digit CSV Code on back

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Enter the message as it's shown*

Please sign with your finger (on a mobile device) or with your mouse (on a computer) to acknowledge that you have read and agree to the Ambu-Care Membership contract and our data collection policy.