AEMTA SPRING FLING
On-Line Registration Form
 using

Please complete and submit the form below. After submission, you will be directed to pay for your registration through PayPal.
You will also have the opportunity to update any society membership dues if you need to do so.
Your registration will not be complete without payment and confirmation from AEMTA.

Full Name: Arkansas EMT #:
Representing: Date of Birth:
Level(s): (hold Ctrl + click for multiple selections)   (for Membership Only)
     
Home Address:
 
City: State:
Zip: County:
Home Phone: (xxx-xxx-xxxx) Work Phone: (xxx-xxx-xxxx)
Cell Phone: (xxx-xxx-xxxx) Email Address:

After Submission, you will be taken to registration payment page.
(Registration is $40)


(Only click submit once)