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APPLICANT INFORMATION
Organization: *
Address 1: *
Address 2:
City: *	State: * ZIP: *
Web Site URL: *
Phone: *	FAX:

ORGANIZATION PRIMARY CONTACT
Name: *
Title: *
E-Mail Address: *
Phone: *	FAX:
Same Address as Organization
Address 1:
Address 2:
City:	State: ZIP:

ORGANIZATION SECONDARY CONTACT #1
Name:
Title:
E-Mail Address:
Phone:	FAX:
Same Address as Organization
Address 1:
Address 2:
City:	State: ZIP:

ORGANIZATION SECONDARY CONTACT #2
Name:
Title:
E-Mail Address:
Phone:	FAX:
Same Address as Organization
Address 1:
Address 2:
City:	State: ZIP:

DESCRIPTION OF COMPANY/ORGANIZATION:


Yes No You may use our organization name on COMCARE materials.

Upload your logo (must be in JPG, GIF, BMP, or PNG format)

AREAS OF INTEREST
Please indicate your areas of interest as a COMCARE member.

	Advanced Technology: Collaborate with practitioners and technology vendors to shape products and advance the use of technology for the transformation of emergency processes.
	Communications and Outreach: Participate in activities aimed at informing and educating the media, emergency responders, the private sector, and non-governmental organizations.
	Enhanced Emergency Medical Response: Work with a variety of professions to bridge the gaps between healthcare, public health and public safety.
	Professional Development: Collaborate with educational institutions to shape educational programs for emergency professionals. Develop informative and educational articles for our publications.
	Public Interest: Work with citizen and public interest groups to promote public understanding of emergency services, build consumer awareness and champion change.
	Public Policy Advocacy: Educate and Inform lawmakers on Capitol Hill and federal officials. Participate on the Public Policy Committee.
	Vehicle Rescue: Participate on initiatives relating to transportation, telematics, extrication, and other vehicle rescue issues.
	Other:

	I agree to all COMCARE Membership Terms and Conditions. Membership dues are based on gross annual revenue. I understand that dues are paid annually on a rolling calendar basis from the date I join COMCARE and know that it is my responsibility to include the relevant fee for annual membership or submit a request for COMCARE to issue an invoice.

	Please send an invoice.

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