OEMTA Membership Application

 Member Information

First Name:         Last Name:        

Home Address:    

City:       State:       Zip:

Phone Number:      

E-Mail:

State License Number:       National Registry Number:

Current OEMTA Number:    License Level: Select OneFirst ResponderEMT-BasicEMT-IntermediateEMT-ParamedicCritical Care ParamedicRegistered Nurse

Current Employer:

 Level Of Membership (all memberships are for 1 year from the time you join)

 Active Member - $40.00

 Student Member - $15.00 (must be a current student)

 Associate Member - $40.00

 Corporate Member - $500.00 (Must be mailed in and include Name, Address, Phone Number, and E-Mail address of each employee covered under the Coporate Membership.  Corporate Membership payable by Check, Moneyorder, or PO Number Only)(Coporate Membership includes 15 members and an additional $25.00 for each member over the 15 limit)

 Payment Method

 Purchase Order (Please submilt the Company Information providing the PO Number)

Company Name:  Company Phone:

Address:  City:  State:  

 Zip:     PO NUMBER: 

 Credit Card (If paying by Credit Card please submit this form, then click on our new Online Store Link located in the left upper corner of the web page to be redirected to a SECURE site for Credit Card Information)

 Check or Money Order (if paying by Check or Money Order please print this form and mail with payment enclosed to: OEMTA, PO Box 864  Norman, OK 73070 or fax to 866.265.8980)

WE NOW ACCEPT ALL MAJOR CREDIT CARDS INCLUDING DEBT AND FEDERAL CARDS.