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Rialto Fire Department Ambulance Membership

  1. 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
  2. Health Insurance Information
  3. Spouse Information
  4. Spouse Health Information
  5. List ALL dependents residing in the home claimed on the previous year tax return
  6. I have verified the above is true and correct.
    Please print and sign application.
  7. Leave This Blank: