REQUEST MEDICAL AIRLIFT SERVICE
(a 501(c)(3) charity)
FIXED WING AIR MEDICAL FLIGHTS PROVIDED BY AIR MEDICAL, INC.line
ARE YOU A CO-OP PARTICIPANT?
PARTICIPANTS ENTITLED TO FREE AIR MEDICAL AIRLIFT!
Please provide all information requested. Thank-you
Planned Itinerary
Flight Date 
Origin of Flight 
Destination - 1st leg
2nd leg (if any)
3rd leg (if any)
4th leg (if any)

Do you need a returning flight?   YES NO

If yes, What is the return date?
Preferred Departure Time
Preferred Return Time
How Many Passengers
Special Instructions?

CO-OP PARTICIPANT ID# 
Full Name
Address
City
State / Zip    
Phone
Fax
E-mail



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