Subscription Payment | Pottsville Area Emergency Medical Services, Inc. Payments

Subscription Details

*This information is required

Subscription Type*

Individual $23
Couple $35
Family $45

Additional Donation Amount

Comments or Additional Information

Primary Subscriber Information

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Subscriber Name*

First Last

Subscriber Address*

Street Address Address Line 2 City State ZIP Code

Subscriber Email

If you enter your email address, you will receive email confirmation that your payment has been received.

Primary Phone*

Date of Birth*

Family Members - Please identify all family members residing in your home

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Name

Date of Birth

Sex

Male
Female

Billing Details

*This information is required

Billing Address*

Same as Subscriber Address

Street Address Address Line 2 City State ZIP Code

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Total

$0.00

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This is a HIPAA and Red Flag Secure and Compliant contact.

Subscription Details

Primary Subscriber Information

Family Members - Please identify all family members residing in your home

Billing Details