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Get Emsrb Longevity Award

LONGEVITY AWARD CLAIM APPLICATION This form must be received in the EMSRB office by October 1 2006 to be paid in the first quarter of 2007. A. Applicant Information The information supplied below is for internal use by the EMSRB. You are not legally required to provide all of the information but we will be unable to calculate your award payment without it. 1. Applicant Name Last First Middle 2. Social Security Number 3. Current Mailing Address please include city and zip code 4. Date of birth 5. List all former last name s I certify that I have terminated active ambulance service am at least 50 years of age and have at least five years of credited ambulance service in the Ambulance Service Personnel Longevity Award and Incentive Program. The information I have provided on this form is true and correct to the best of my ability. A. Applicant Information The information supplied below is for internal use by the EMSRB. You are not legally required to provide all of the information but we will be unable to calculate your award payment without it. 1. Applicant Name Last First Middle 2. Social Security Number 3. Current Mailing Address please include city and zip code 4. Date of birth 5. List all former last name s I certify that I have terminated active ambulance service am at least 50 years of age and have at least five years of credited ambulance service in the Ambulance Service Personnel Longevity Award and Incentive Program* The information I have provided on this form is true and correct to the best of my ability. Applicant signature Date The affidavit below must be signed by the chief administrative officer of ambulance service and then notarized* STATE OF MINNESOTA Affidavit of Termination of Service County of Name of chief administrative officer and belief the person named above who is applying for an Individual Longevity Award has terminated from active service in the service for which the affiant speaks and meets the qualifications for the Longevity Award in Minnesota Statutes 144E*46. Further affiant the information contained on this from is true and correct to the best of the affiant s ability. Further affiant sayeth not. Chief Administrative Officer Signature Notary Public Signature Subscribed and sworn before me this day of 20. INSTRUCTIONS Provide applicant s name - last first middle. List any and all names under which applicant s service may be registered* Applicant must sign and date form*. A. Applicant Information The information supplied below is for internal use by the EMSRB. You are not legally required to provide all of the information but we will be unable to calculate your award payment without it. 1. Applicant Name Last First Middle 2. Social Security Number 3. Current Mailing Address please include city and zip code 4. 1. Applicant Name Last First Middle 2. Social Security Number 3. Current Mailing Address please include city and zip code 4. Date of birth 5. List all former last name s I certify that I have terminated active ambulance service am at least 50 years of age and have at least five years of credited ambulance service in the Ambulance Service Personnel Longevity Award and Incentive Program* The information I have provided on this form is true and correct to the best of my ability.

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