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BUSHKILL EMERGENCY CORPS
SUBSCRIPTION REQUEST
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NAME ____________________________
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ADDRESS _________________________
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PHONE # _________________________
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HEALTH INS. NAME (if any) ___________
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Insurance Group # _________________
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Policy # __________________________
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Policy holder's name ________________
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Please list household members with ages:
COST:
(Circle plan choice)
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$50.00 for individuals
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$70.00 for Family
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NEW: $50.00 for couples over 60 years old
(please circle payment method)
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Check enclosed
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Visa
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Mastercard
Card Number _____________
Expiration Date ____________
Signature ________________
Please make checks payable to:
Bushkill Emergency Corps
C/O PNC Bank
P.O. Box 4515
Philadelphia, Pa., 19182-4515
Mail to:
Bushkill Emergency Corps
P.O. Box 174
Bushkill, Pa., 18324