Fillable Ambulance Subscription Program 2021 RENEWAL FORM **Subscriptions expire (City of Gustavus)

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Ambulance Subscription Program 2021 RENEWAL FORM **Subscriptions expire (City of Gustavus)

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For Office Use Only:
Amount $__________ Cash Receipt #_________ Ck#__________ CC Authorization __________
Date Paid__________ Initials ________Entered _______ Notes__________________________________
City of Gustavus
PO Box 1
Gustavus, Alaska 99826
Phone: (907) 697-2451
Ambulance Subscription Program
2021 RENEWAL FORM
**Subscriptions expire annually on December 31st.**
Subscriber(s)_______________________________________________
__________________________________________________________
Subscription Type: Household $25
Individual $10 each
Changes in household subscribers since previous year:
___________________________________________________________
Changes to insurance since previous year (provide copy of card):
____________________________________________________________
____________________________________________________________
Signature ______________________________ Date_____________
Per City of Gustavus Municipal Code 6.02 and Resolution CY19-18.
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Ambulance Subscription Program 2021 RENEWAL FORM **Subscriptions expire (City of Gustavus)

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Completed 23 January 2021

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