THE GOLDEN KEEP CARD SIGN UP FORM

Golden Keep Card

Sign Up Form

Your Full Name

Shipping Addr

Home Phone

Work Phone

Email Address

Social Security #

(for reporting of profit sharing earnings)

Relatives Full Name	Relation
	wife husband
	son daughter
	son daughter
	son daughter

If this list should change at any time, please give us a call and let us know öthank you.

*Six months from the day your sign up form is processed ö you and your immediate family will have private air-medical jet service available, free of charge, should you need it.

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Payment Option #1

I would like to make the payment for my Golden Keep Card in:

12 Monthly Payments of $10.50
or,
One Payment of $120

I understand that I will receive the following benefits for this level of participation:

Private air-medical jet transportation for me and/or my immediate family in the event of serious illness or injury.
A monthly check from the Golden Keep Foundation as part of my automatic participation in the Co-Op Profit Sharing Program.
Satisfaction of knowing that I am helping AMSA in their efforts to improve air-medical coverage in rural communities.
A complimentary copy of AMSAâs Quarterly Newsletter.

Payment Option #2

I would like to make the payment for my Golden Keep Card in:

12 Monthly Payments of $15.50
or,
One Payment of $186

I understand that I will receive the following benefits for this level of participation:

All the benefits for Option 1,

plus,

One free product of my choice (per month) due to my extended level of participation in the Golden Keep Foundation's Co-Op Profit Sharing Program. Choose from the products listed below.

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Method of Payment
I would like my payment(s) automatically deducted from my:
Charge Card

Name on Card:
Card #
Exp. Date:

Checking Account

Account #
Bank Name:
City/State/Zip:

I authorize the above debit transaction(s) to take place.
Check the boxSignature Date

Member Who Introduced you to this program: