Application for license

An application for a basic life support ambulance service or advanced life support ambulance service license shall be submitted on a form or through an electronic process, as prescribed by the department. The application must contain the following information as well as additional information and documents that may be solicited by the application form: 1. The name and mailing address of the applicant and a primary contact individual and telephone number and electronic mail address at which that individual can be reached. 2. The name under which the applicant shall hold itself out to the public in conducting its emergency medical service operations and the address of its primary location in this state out of which it shall conduct its emergency medical service operations. If the applicant seeks to conduct emergency medical service agency operations out of more than one location, the address of its primary operational headquarters and each other location out of which it intends to operate must be provided. If the applicant holds itself out to the public under different fictitious names for the emergency medical service operations it conducts at different locations, the fictitious name under which it intends to operate at each location must be provided. 3. The manner in which the applicant is organized. 4. The tax status of the applicant. 5. The geographic area for which the applicant intends to provide service. If the service is a type of service that is dispatched by a public safety answering point, the applicant shall detail the geographic area, if any, in which it plans to routinely respond to emergency dispatches. 6. A personnel roster. 7. The number and types of emergency medical service vehicles to be operated by the applicant and identifying information for each emergency medical service vehicle. 8. The communication access and capabilities of the applicant. 9. A full description of the emergency medical service agency services that the applicant intends to provide out of each location and how it intends to respond to emergency calls if it will not conduct operations out of a fixed location or locations. 10. The names, titles and summary of responsibilities of individuals who will be staffing the emergency medical service operation as officers, directors, or other emergency medical service agency officials. 11. A statement attesting to the veracity of the application, which shall be signed by the principal official of the applicant.