Mutual Aid Agreements List any services with which you have written agreements. Include any mutual aid, ALS intercept, tiered response, backup agreements, etc. Name Describe relationship Transportation List ALL vehicles used if a transporting service. All transporting services must maintain at least one ambulance vehicle in good operating condition Local Unit WI License Year / Conversion Date last DOT VIN Model Vehicle type No. Plate No. Make Mfg. Inspection SIGNATURE PAGE TO ACCOMPANY FORM NUMBER F-47463 Name of EMS Provider Provider License Number OWNER / OPERATOR CERTIFICATION I certify that the information submitted on form F-47463 is true and complete to the best of my knowledge. I further certify that the named EMS service will operate in conformance with s. 256.12 and s. 256.15, Wisconsin Statutes and Chapter 110 Wisconsin Administrative Code. The EMS service will comply with the specifications and standards of the Wisconsin statewide emergency medical services communications system. The EMS service will use the Department's run report form or a copy of an alternative report form will be provided to the Department for review and approval prior to its use. All runs will be documented on this ambulance report form and all forms will be kept and distributed in compliance with Wisconsin Statutes and Administrative Codes pertaining to patient medical records. SIGNATURE Owner Date Signed –
Mutual Aid Agreements List any services with which you have written agreements. Include any mutual aid, ALS intercept, tiered response, backup agreements, etc. Name Describe relationship Transportation List ALL vehicles used if a transporting service. All transporting services must maintain at least one ambulance vehicle in good operating condition Local Unit No. WI License Plate No. VIN Year / Make Model Conversion Mfg. Vehicle type Date last DOT Inspection SIGNATURE PAGE TO ACCOMPANY FORM NUMBER F-47463 Name of EMS Provider Provider License Number OWNER / OPERATOR CERTIFICATION I certify that the information submitted on form F-47463 is true and complete to the best of my knowledge. I further certify that the named EMS service will operate in conformance with s. 256.12 and s. 256.15, Wisconsin Statutes and Chapter 110 Wisconsin Administrative Code. The EMS service will comply with the specifications and standards of the Wisconsin statewide emergency medical services communications system. The EMS service will use the Department's run report form or a copy of an alternative report form will be provided to the Department for review and approval prior to its use. All runs will be documented on this ambulance report form and all forms will be kept and distributed in compliance with Wisconsin Statutes and Administrative Codes pertaining to patient medical records. SIGNATURE – Owner Date Signed