AIR EVAC LIFETEAM

NAME:__________________________________ SS#_________________

ADDRESS:____________________________________________________________

______________________________________________________________________

HOME PHONE: ____________________

WORK PHONE: ____________________

I HEREBY AUTHORIZE PAYROLL DEDUCTION FOR AIR EVAC. $50 Coverage for anyone living in the household COVERAGE STARTS THE 1ST OF THE MONTH FOLLOWING DEDUCTIONS. PAYMENTS ARE MADE THROUGH PAYROLL DEDUCTION. □ NOT INTERESTED

□ PREVIOUS MEMBER *PLEASE FILL OUT THE MEMBERSHIP ENROLLMENT ON THE NEXT PAGE.

Signature Date

Membership Application - North Arkansas College

Loren Tepper • 870-280-9325 • Loren.Tepper@amgh.us13266 120

$4.17