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Membership Application

Note: If you do not wish to submit the following information via the Internet, please print this form, and fax to (203) 881-5018 or mail it to:

Seymour Ambulance Association, Inc.
4 Wakeley St.
Seymour, CT 06483

 

Applicant Information
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Contact Information
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  2.  (valid email required)
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Employer Information
Certifications / Licenses
Questions / Comments
Membership Agreement
  1. I certify that the information listed above is true to the bset of my knowledge, and that I will abide by the constitution and by-laws of the Seymour Ambulance Association, Inc. I further understand that all new applicants are subject to a criminal records check.
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