Application for license

An application for licensure as an emergency medical services training institution may be submitted on a form provided by the department or an alternate format which includes the following information: 1. Applicant information: a. Name of the training institution; b. Mailing address; c. Telephone number; d. Name of program coordinator; e. Name of training institution medical director; and f. E-mail address of contact person; 2. A copy of the written agreement with the physician medical director; 3. A copy of the written agreement with the hospitals, clinics, ambulance services, and physicians' offices that will provide field internship training; 4. A listing of the names of the persons or organizations that have financial interest in the institution; 5. A copy of the student handbook for the institution; and 6. A signed statement attesting to the accuracy of the application and all of its attachments.