Fire Med Application

Yes! I want to join FireMed!
Membership is available to all residents of Huntington Beach. The membership fee covers all people who live at the residence.
Add the $5 monthly payment to my Municipal Services Statement
        Municipal Services Statement must be in the same name as noted in applicant
        information below

Bill me annually for $60

(a low-income membership rate is available - please contact our office for details)
* = required

First Name*
Last Name*

(Just one person's name from the household is required, and will be used for contact purposes only.   FireMed membership is confirmed by the home address in Huntington Beach, not the name submitted on the membership application.)

Home Address *
Apt./Unit #
City
HUNTINGTON BEACH
Zip Code*
Home Phone Number*
Alternate Phone Number
Type
Number in Household*
Email Address*

Mailing Address (if different from address of residence)

Street Address
City
Zip Code
State

I have read and agree to the terms and conditions of the Huntington Beach Fire Department FireMed Program *




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