Please fill out and submit the following form. You will be emailed an invoice which you must then print out, and mail in along with a check for your payment.

Make all checks payable to KEMA. Invoice and payment must be mailed to:

Chester County Department of Emergency Services
c/o Tony Przychodzien, Jr., KEMA Treasurer
601 Westtown Road, Suite 012
P.O. Box 2747
West Chester, PA 19380-0990

All fields are required.

Membership Type:	Regular - $30.00 Student - $15.00 Affiliate - $120.00 Organizational - $120.00
Name:
Title:
Agency:
Email:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Date:
If you are purchasing an Organizational membership, please provide the names of your members in the boxes below. Otherwise, leave this section blank.
Member 1:
Member 2:
Member 3:
Member 4:
Member 5: