Application for license

An application for an air 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. Contact information: a. The name, mailing address, and electronic mail address of the applicant. b. A primary contact person, including telephone number, to be reached twenty-four hours per day seven days per week. 2. The name under which the applicant will be holding 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 will be conducting its emergency medical service operations. a. 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 also be provided. b. If the applicant will be holding itself out to the public under different fictitious names for the emergency medical service operations it will conduct at different locations, the fictitious name under which it intends to operate at each location. 3. The manner in which the applicant is organized. 4. The tax status of the applicant. 5. An up-to-date roster of active personnel. 6. The number and types of aircraft to be operated by the applicant and identifying information for each aircraft. 7. The communication access and capabilities of the applicant. 8. A full description of the emergency medical service agency services that it intends to provide out of each location and how it intends to respond to flight transport requests. 9. 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. 10. A statement attesting to the veracity of the application, which must be signed by the principal official of the applicant.