Florida Association of Medical Equipment Services
       2805 8th Avenue West
       Bradenton Florida 34205
       Phone: 941-448-5898 
       E-mail: FloridaFAMES@aol.com • Website: www.famesonline.com


Membership Application
Membership Year  2016
(The FAMES membership year runs from July 1st through June 30th, or January 1st through December  31st. )

Membership Dues:
Active Membership   $425.00 for first (or single) location                           Associate Membership     $425.00
                                              $60.00 per location for each additional location
Corporate Level Sponsorchips are available with special pricing - Contact the FAMES Office





Please include your paperwork with payment.

Do you require an invoice?  Yes__   No__

Payment Information:
  Check payable to FAMES $_____________
 ***Charge my:    VISA    MASTERCARD        Card #___________________________________   

Expiration Date ___________   Sec Code __________

Name on Card: _________________________________   Signature of Card Holder: _________________________________


  YES I would like to take advantage of the new FAMES Quarterly billing of $106.25 per quarter billed to my Credit/Debit Card

Accredited? Yes ( ) No ( )           If yes, by whom? ACHC ( ) CHAP ( ) JCAHO ( ) HQAA ( ) Other _______

We have _____location(s). (All locations of a member company must join.)

CompanyName_________________________________________________________

Contact Name:__________________________________________________________

Address: ______________________________________________________________

City/State/Zip:__________________________________________________________

Phone ____________________________________________

Fax*______________________________________________

Email**______________________________________________________________________

*FCC regulations require that we gain permission to send faxes to members; urgent communications about the industry are occasionally sent via fax, as are other items of interest. Providing your fax number will be construed as permission to send faxes.
**E-mail addresses are required. Information from FAMES, including the quarterly newsletter, is most often sent via E-mail (a separate fax list is not maintained).

Your Privacy
*FAMES does not provide or sell member contact information to nonmembers or interested industry entities. All members of FAMES (full/regular and associates) do have access to the membership list. If you want your information withheld from FAMES members, please designate this next to your Company information.

*Please provide all applicable contact and mailing information for each location of your member company so that our FAMES mailings, faxes, and E-mails can be directed correctly (an additional contact sheet is included).
On the next page we’re asking for more information about your company. 

 The FAMES office gives referrals to out-of-state companies on a regular basis; details about your company will help make this process as efficient as possible. Please take a moment to answer the questions and send them to the office. My company provides the following products and services (check all that apply):

____ Oxygen          ____ Respiratory Equipment

____ Hospital Beds and Accessories       ____ Medical/Surgical Supplies

____ Pharmaceuticals    ____ Diabetic Supplies

____ Wound Care/Skin Care   ____ Wheelchairs/Walkers/Canes

____ Power Wheelchairs/Scooters ____ Lifts

____ Incontinence/Urological/Ostomy    ____ Diagnostics

____ Orthotics/Prosthetics     ____ IV Therapy

____ Aids to Daily Living              ____ Other (Please specify) _________________________________________

Please let us know if you’ll accept referrals:
____ Yes, we will accept referrals for visiting patients.
____ No, we will not accept referrals for visiting patients.



Please make your membership check payable to FAMES and mail with your completed application to:

Florida Association of Medical Equipment Services
2805 8th Avenue West
Bradenton Florida 34205


 Thank you!

Joan A. Cross, AA
Executive Director



FAMES Membership: Additional Locations

Company Name

Contact

Address

City State Zip 

Phone Fax

E-Mail
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Address

City State Zip

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Company Name

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Address

City State Zip

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THE Florida Association of Medical Equipment Services
Serving the medical equipment industry continuously since 1982
To Make It Easy, Just Print Out This Page and 
Send It In With Your Payment
Pursuant to the Lobbying Act of 1993, FAMES expects to use 20% of membership dues for lobbying efforts during the membership year. Therefore, up to 80% of the dues are deductible (consult your accountant or financial adviser for exact applicable percentage). FAMES dues are nonrefundable.
*** If the address associated with the credit card is different than your business address, please include it with credit card information:________________________________________________________________________________________