Kentucky Association of Emergency Medical Technicians
P.O. Box 178
Elizabethtown Kentucky 42702

EMS-FIRE CUBE
 ORDER FORM

Please Print Legibly or Type in the Form and Print

Date Ordered 

 First Name      Last Name

 ADDRESS:

 CITY     State     Zip

 TELEPHONE: 

Email: 

 Cube order  INFORMATION (check appropriate method): Each Cube is $5.00

       KAEMT      EMT-B       EMT-P      FIREFIGHTER   EMT-FR 

SHIPMENT INFORMATION : (First class via United States Postal Service.)

Please ship the completed order at my expense to: Shipping cost is $2.50 per cube.

NAME:   
                 First Name                                                                 Last Name

ADDRESS:

 CITY     State     Zip

PAYMENT INFORMATION (check appropriate method):

Advance payment required via Check, Money Order Please do not send cash.

GRAND TOTAL ALL ITEMS    $         Check    Money Order     

Please make checks payable to: KAEMT Inc

Mail to:  EMS-FIRE CUBE
            KAEMT Inc
             P.O. Box 178
                    Elizabethtown Kentucky 42702

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