Fire Medics Application

Yes, I want to join the Fire Medics Program!
Membership is available to Newport Beach residents or business owners.

• For residents who receive a municipal services statement from the City of Newport Beach, a membership fee of $14 will be added to your bi-monthly bill ($84/year).
• For qualifying business members, the fee structure is as follows:
  • $84 standard subscription fee for business with 10 owners and employees.
  • $25 additional charge per group of 10 owners and employees for a maximum of 150 employees (14 additional groups) and a maximum subscription fee of $434.
• Residents or Business Owners that do not receive a municipal bill will be invoiced the full membership fee annually.
• Learn more about the Fire Medics program.

1

First Name:

 *

First Name:

2

Last Name:

 *

Last Name:

3

Business Name:

Business Name:

4

Service Address:

 *

Service Address:

5

Apartment # or Suite:

Apartment # or Suite:

6

City:

 *

City:

7

Zip Code:

 *

Zip Code:

8

Phone:

 *

Phone:ext.

9

Number of people in home or business:

 *

Number of people in home or business:

10

Email Address:

Email Address:

11

Mailing Address (if different from above):

Mailing Address (if different from above):

12

City:

City:

13

State:

State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

14

Zip Code:

Zip Code:

15

 Preferred Method of Contact:

 *

Preferred Method of Contact:

Phone

Email

U.S. Mail

**Your information will be kept confidential. We will not release your information to anyone else.

www.newportbeachca.gov/firemedics

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