If the dispatch facilities are not located at the Ambulance Service address, please provide the following: Street City State Zip Non-Emergency Telephone: ( ) MEDICAL DIRECTOR A letter from a licensed physician accepting off-line medical direction must be submitted with the application. Rule 1200-12-1-.14 explains the functions of the Medical Director. In addition to the letter, please identify the Medical Director and provide the following information: service’s Name of Medical Director: Mailing Address: Street City State Zip Office Telephone: ( ) Fax: ( ) Email Address: Profession License Number: VEHICLE MARKINGS All ambulances operated by a service must meet the design and marking specifications as outlined in 1200-12-01-.02 (3) and receive approval prior to permitting. Submit a color photo or color drawing reflecting the color and marking scheme to be approved. The photos/drawings must include both sides, rear, front and top of the vehicle. VEHICLE PERMITS All Ambulances operated by the service must have a permit. Apply for permits by providing a listing of all vehicles with the information requested on the enclosed form titled: New Service-Vehicle Permit Information. MECHANICAL SAFETY INSPECTION A Mechanical Safety Inspection form (PH-2405) for each vehicle requesting to be permitted must be submitted with the application. FEES ACTION INITIAL AMBULANCE SERVICE INITIAL VOLUNTEER AMBULANCE SERVICE License Fee $5,000.00 $2,000.00 $250.00 Per Vehicle $100.00 Per Vehicle Vehicle Permit Fee No. of Vehicles No. of Vehicles TOTAL FEES TO BE SUBMITTED $ ENCLOSE A CHECK OR MONEY ORDER FOR TOTAL FEES MADE PAYABLE TO: TDH-
If the dispatch facilities are not located at the Ambulance Service address, please provide the following: Street City State Zip Non-Emergency Telephone: ( ) MEDICAL DIRECTOR A letter from a licensed physician accepting off-line medical direction must be submitted with the application. Rule 1200-12-1-.14 explains the functions of the Medical Director. In addition to the letter, please identify the service’s Medical Director and provide the following information: Name of Medical Director: Mailing Address: Street City State Zip Office Telephone: ( ) Fax: ( ) Email Address: Profession License Number: VEHICLE MARKINGS All ambulances operated by a service must meet the design and marking specifications as outlined in 1200-12-01-.02 (3) and receive approval prior to permitting. Submit a color photo or color drawing reflecting the color and marking scheme to be approved. The photos/drawings must include both sides, rear, front and top of the vehicle. VEHICLE PERMITS All Ambulances operated by the service must have a permit. Apply for permits by providing a listing of all vehicles with the information requested on the enclosed form titled: New Service-Vehicle Permit Information. MECHANICAL SAFETY INSPECTION A Mechanical Safety Inspection form (PH-2405) for each vehicle requesting to be permitted must be submitted with the application. FEES ACTION INITIAL AMBULANCE SERVICE INITIAL VOLUNTEER AMBULANCE SERVICE License Fee $5,000.00 $2,000.00 Vehicle Permit Fee $250.00 Per Vehicle No. of Vehicles $100.00 Per Vehicle No. of Vehicles TOTAL FEES TO BE SUBMITTED $ ENCLOSE A CHECK OR MONEY ORDER FOR TOTAL FEES MADE PAYABLE TO: TDH-
PH-3987%20Initial%20GRND%20Srvc%20Lic%20APP%208.20.18.docx