UNYAN :: Membership Application

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Membership Application

Instructions: Your TAB Key allows you to navigate forward through the series of questions and to activate input text boxes. SHIFT + TAB allows you to navigate backwards though the series of questions.
Your TAB key + Space bar will allow you to select checkboxes.
Your ARROW keys allow you to navigate through a series of radio buttons after making the first in a series active using your TAB key.

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Membership Application Company Name:
Address:
Email:
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Phone:
Fax:

Staff Info President/CEO:
Director:
Marketing Director:

Services Provided

ALS Ambulance

Hours:

BLS Ambulance

Hours:

Wheelchair

Hours:

Other (Please Specify):

Number of Vehicles ALS Ambulances:
BLS Ambulances:
Fly Cars:
Response Vehicles:
Wheel Chair Vans:
Other:

Personnel :: Number of Employees Full-time:
Part-time:

Personnel :: Number of Certified Employees Paramedic:
Critical Care Tech:
Intermediate:
EMT-D:
EMT:
EMD Certified:
Dispatchers:
Drivers:
Supervisors:
Other:

Minumum Ambulance Staffing Requirement: Minumum Ambulance Staffing Requirement:

Annual Billable Call Volume: ****

**** Please note:: Your dues will be based on the annual billable call volume for you ambulance business only. Call volume is for the use of the UNYAN Treasurer ONLY for the purpose of calculating annual dues. Call volume will not be shared with any other UNYAN Board Member, Director, or Member.

ALS:
BLS:
Wheelchair:
Other:

Call Reception Call Reception:

How your company receives emergency, non-emergency, wheelchair and other calls: (Please Specify - via 911, via fire control, etc.)

Area of Operation Area of Operation:

Please describe your company's area of operation.

Service Area Institutions Institution list:

Please list major institutions within your service area; include hospitals, nursing homes, etc.

Managed Care Providers MCP's in service area list:

Please list the Managed Care Providers in your service area; include all HMO's.

Rate Information - (Optional) ALS:
BLS:
Wheelchair:
Mileage:
Are all Rates Inclusive? No Yes
Other: