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2. First Name*
3. Last Name*
5. Date of Birth*
7. Service Address Covered by Subscription*
9. City*
10. State*
11. Zip*
13. Name of Individual to Send Reminder Notices to*
15. Mailing Address for Reminder Notices*
17. City*
18. State*
19. Zip*
21. Telephone*
22. Alternate Telephone
24. Email*
    Email address will be used in lieu of a signature. You will not be sent spam or promotional emails.
26. Submit Payment
    *Please note, your ambulance subscription will not be active until payment has been received on the account. To submit a payment, you may either pay over the phone with a credit card by calling 918-376-1520, or you may pay with cash, check, or credit card during business hours at City Hall. Checks payable to City of Owasso.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

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