*$1,395.00

$1,395.00 by January 31st. or 1,495.00 after january 31st

*$895.00

$895.00 By January 31st or $995.00 after January 31st

Has any family and/or household member(s) of the applicant who has ownership or control interest in the enrolling business or entity? If yes, please supply the name of family/household member and relationship to applicant.

Yes No

Check below if the applicant has ever had any of the following adverse legal actions imposed by the Medicare, Medicaid or any other federal agency program. For each item checked, include the date of the adverse legal action.

Authorization of Disclosure and Release of Information
Wisconsin Association of Medical Equipment Services

In connection with my application for membership to the Wisconsin Association of Medical Equipment Services (hereinafter known as "WAMES"), I authorize WAMES and/or Fidelitec, LLC, to investigate and retrieve information relating to my past activities for purposes of such investigation from all relevant individuals and organizations, including but not limited to government agencies, companies, law enforcement agencies, and sonsumer reporting agencies, to supply andy and all information conerning my background, and release the same from any liability resulting in providing such information. The information received may include, but is not limited to, criminal records, civil records, and related court offenses. I understand that I have the right to request additional information about these inquiries and any subsequent reports. THis additional information will be provided to me upon written request to Fidelitec, LLC, 245 Horizon Drive, Suite 107, Verona, WI 53593.

I hereby certify that all the statements and answers made by me, both verbal and in writing, including statments on this form are true and complete to the best of my knowledge, and I understnad that any false statements and/or answers or omissions of information and on this form will be sufficient cause for cancellation of my application or dismissal, if I have been granted membership. I understand that by furnishing my birth date below, WAMES and/or Fidelitec, LLC, are using that information for the sole purpose of verifying identification as part of the criminal records check and the birth date is not part of my application for membership. I release all parties for all liability for any damage that may result from furnishing information, including this disclosure of my date of birth and this authorization to WAMES and/or Fidelitec, LLC.

I authorize that a photocopy or fax of this authorization be accepted with the same authority as the original; and that this authorization be in effect throughtout my consideration for membership and, if granted by WAMES, this authorization remain in effect throughout my membership.