Ownership (check only one) Individual Corporation / /
Event
Man-Made Disaster / /
Facility
Commercial Hospital Based Independent Industrial Fire Department Municipal/Government College / /
IndustryTerm
Incomplete applications / radio systems / non-commercial services / /
OperatingSystem
DOS / /
Organization
Department of State / EMS Operating Certificate Bureau of Emergency Medical Services / NEW YORK STATE DEPARTMENT OF HEALTH Application / Ambulance Service ALS First Responder Service / Commercial Hospital Based Independent Industrial Fire Department Municipal/Government College / Federal Communications Commission / DOH Area Office / Medicare / _____________mhz Agency / /
Person
Dispatch Method / / /
Position
Treasurer / CEO / Captain / Operations Manager / Address________________________________________ Phone______________ Chief Operating Officer / President / Private / Home Secretary / Vice President / COO / EMT-Critical Care EMT-Paramedic / Medical Director / official corporate name / /
Application for EMS Operating Certificate