Home Careers Education Patients Facilities Compliance Coverage Employees Contact Name* First Name Last Name Phone* Email* Organization Name* Event Name* Is EMS Coverage required for your event?* Yes No EMS Coverage Type Requested* ALS BLS Hours required (Full Hour Incrememnts)* Card Billing Name* First Name Last Name Card Billing Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Credit Card (ALS = $150/hr || BLS = $125/hr) Total to Charge $ Event Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Event Description* Date/Time of your Event* Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 01 02 03 04 05 06 07 08 09 10 11 12 : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 AM PM Were you referred to Jan-Care Ambulance Service* Yes No You must acknowledge the following:* I acknowledge that this request, regardless of how early it is submitted, does not guarantee that Jancare Ambulance will be able to provide standby service for my event You must acknowledge the following* I agree to call 304-253-0983 and ask to speak to the dispatch supervisor. Question or Comments (you can also email cparsons@jancare.com) HTML Form Creator © 2021 by Jan-Care Ambulance Service Inc. All rights reserved.