Staunton Augusta Rescue Squad

Account Number

First Name *

Initial

Last Name *

SSN# (Optional)

Date of Birth *

Address *

City *

State *

Zip/Postal Code *

Phone *

Email *

Other Household Members

List other members in household if any

Other Household Members *

	Yes
	No

Certification

I certify that I do not have health insurance coverage for myself or the members of my household listed above.

Certification *

Yes I Certify

Signature

Please type your full name here.

Signature Name *

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

Agreement *

Yes, I Agree

Payment

Please remit your payment below. The fee for the subscription program is $150.00 annually.

Amount Paid *

First Name*

Last Name*

Exp. Month / Exp. Year*

/

(mm/yyyy)

Card Type*

Card Number*

Security Code *

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