Application

New York State Association of Fire & Lifesafety Educators Membership Application

                                                      ___ New                                       ___ Renewal

Name: _______________________________

Address: _________________________________               City: ___________________

State: ___________                Zip Code: ____________

e-mail: _________________________________________

Affiliation: ( Please check all that apply)

          ___ Firefighter        ___  Educator        ___  EMS        ___  Fire Administrator       ___ Sponsor

Affiliation fire company name: _________________________________________________

Membership level:        ___ Individual Active                                                   $10.00

                                          ___ Sustaining / Organizational                               $50.00

ACTIVE MEMBER: Persons eligible to become active members are individuals who have an interest in fire and life safety education and are willing to fulfill the objectives and purposes of the association.
SUSTAINING MEMBER: Those eligible to become sustaining members are individuals, firms, corporations, institutions, societies, associations, board, bureaus, or commissions wishing to assist in attaining the objectives of the association.
ORGANIZATIONAL MEMBERS: Emergency service organizations are eligible to become organizational members. Each organizational membership is entitled to have 5 active members listed on the association mailing list. Mail will be sent to all 5 members.

For organizational memberships, please fill out an application for each member to be listed under the organizational membership. Please enclose a check for the appropriate amount and send to the address below.

Signature_______________________________                   Date___________________