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Membership Application
 

Membership Application

Click here for a PDF Membership Form

Each entity seeking to become a member of the AAA must submit accurate information on the membership application. Each ambulance service wishing to be an Active Member of the AAA is required to declare certain information on the initial membership application and on the annual membership renewal notice:

  1. Each single-state ambulance service is required to declare (on the initial membership application and annual membership renewal notices) all of the ambulance vehicles that are licensed to transport patients.
  2. Each multi-state ambulance service is required to declare (on the initial membership application and annual membership renewal notices) each state in which they maintain an ambulance operation.

Standards of Conduct

In order to be considered for membership or retain membership in good standing, no person or organization can be found to have violated any of the provisions listed below:

  1. Willful violation, resulting in a conviction, of any federal, state or local laws, including- fraud, larceny, bribery or other egregious felonies, that would have an adverse effect on the ambulance industry.
  2. Falsification of any information submitted to the Association.
  3. Failure to meet any financial obligation justly due the Association.
  4. Willful acts to discredit the Association.
  5. Representing the Association or expressing an opinion in the name of the Association without official authority.
  6. Theft or misappropriation of any property or any act to defraud the Association.
  7. Engaging in any activity which may conflict with the interests, goals, and objectives of the Association.
  8. Employee recruitment at any Association sponsored function.
  9. Any inappropriate use of Association materials, resources and information.
  10. No member shall knowingly engage in any illegal self-referral patterns. Illegal is meant to be any violation federal anti-kickback statutes.

I understand that this application is subject to the approval of the Board of Directors of the Association after it has been reviewed and that, if this application is not accepted all fees paid will be refunded in full. Until such time, I shall be designated as a member applicant. If elected to membership, I pledge to conform to the articles, by-laws, code of ethics, professional standards and other official acts of the American Ambulance Association.

Select Membership Type
Organization Name
Title
Contact Name
Job/Position Title
Business Address
City/State/Zip
Email Address
Work Phone
Work Fax
Web Address
Population Served - Select One
Annual Number of Service Requests
Annual Number of Transports
Annual Number of Medicare Billed Transports
Top 5 cities/towns that make up the largest % of your transports:
Percentage of Transports Classified as Urban
Percentage of Transports Classified as Rural
Perecntage of Transports Classified as Super Rural
Percentage of Transports Classified as Emergency
Percentage of Transports Classified as Non-emergency
Percentage of Transports Classified as Medicare
Percentage of Transports Classified as Medicaid
Percentage of Transports Classified as Private Pay
Percentage of Transports Classified as Self Pay
Percentage of Transports Classified as No Pay
Percentage of Transports Classified as Other
Number of Registered Ambulances
Number of States Served
Total Number of Employees
Number of Full Time Employees
Number of Part Time Employees
Number of Volunteers
Who is the Congressman for your main location?
What other members of congress represent the geographical areas you serve?
If you are a primary or back-up emergency provider, who regulates your services?
Ownership Classification - Check All that ApplyBusiness Sole Proprietorship Partnership Privately-held Corporation Publicly-held Corporation Non-profit Corporation Government City/County/Community
Ownership Classification ContinuedCommunity Fire Department Volunteer Police Department Hospital Owned EMS Authority Other
Services Provided - Check All that ApplyPrimary Emergency Provider Backup Emergency Provider Inter-facility Transports First Responder Services Stretcher Transports Wheel-chair Transports
Affiliate Members - Check All that ApplyAmbulance Accessories/Equipment Ambulance Refurbish/Conversion Ambulance Sales/Manufacturing Communications Hardware/Software
Affiliate Members ContinuedConsulting/Management Education/Training Financial Administration Insurance Legal Services Patient Handling/Supplies
Additional Representative Name and Email Address #1 (optional)
Additional Representative Name and Email Address #2 (optional)
Additional Representative Name and Email Address #3 (optional)
Additional Representative Name and Email Address #4 (optional)
Additional Representative Name and Email Address #5 (optional)
Method of Payment
Validation Code


 

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