Ambulance Membership Program

2. Please complete the application, print and submit to:

   Rialto Water Services - In person: 437 N. Riverside Ave., Rialto, CA 92376 Mail in: P.O. Box 800 Rialto, CA 92377.  $60 annually or $5 a month on your Rialto Water Services Bill. if you are part of West Valley Water District, you can still submit this application to Rialto Water Services.

4. Name of Primary Member:*
5. Email Address
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Cellphone Number
16. Date of Birth*
17. Social Security Number*
19. Health Insurance Information
21. PRIMARY Health Insurance Provider*
23. Policy or Group Number*
24. Insurance Phone Number*
26. Insurance Address*
28. SECONDARY Health Insurance Provider
30. Policy or Group Number
31. Insurance Phone Number
33. Insurance Address
35. Spouse Information
37. Name
38. Email Address
40. Address
42. City
43. State
44. Zip Code
46. Phone Number
47. Cellphone Number
49. Date of Birth
50. Social Security Number
52. Spouse Health Information
54. PRIMARY Health Insurance Provider
56. Policy or Group Number
57. Insurance Phone Number
59. Insurance Address
61. SECONDARY Health Insurance Provider
63. Policy or Group Number
64. Insurance Phone Number
66. Insurance Address
68. List ALL dependents residing in the home claimed on the previous year tax return
70. #1 - Name
72. Date of Birth
73. Social Security Number
75. #2 - Name
77. Date of Birth
78. Social Security Number
80. #3 - Name
82. Date of Birth
83. Social Security Number
85. #4 - Name
87. Date of Birth
88. Social Security Number
90. #5 - Name
92. Date of Birth
93. Social Security Number
95. #6 - Name
97. Date of Birth
98. Social Security Number
100. First Name
101. Last Name
103. I have verified the above is true and correct.
     Please print and sign application.
105. Signature of Primary Member
106. Date
Leave This Blank:


107. Print Only

* indicates a required field