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BUSHKILL EMERGENCY CORPS

SUBSCRIPTION REQUEST

  • NAME ____________________________

  • ADDRESS _________________________

  • PHONE # _________________________

  • HEALTH INS. NAME (if any) ___________

  • Insurance Group # _________________

  • Policy # __________________________

  • Policy holder's name ________________

  • Please list household members with ages:

 

 

COST:

(Circle plan choice)

  • $50.00 for individuals

  • $70.00 for Family   

 

  •  NEW: $50.00 for couples over 60 years old 

(please circle payment method)

  • Check enclosed

  • Visa

  • 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