Voluntary Ambulance Inspection Program Application

Voluntary Ambulance Inspection Program Application

Please complete this form and upload all attachments before submitting.

Date of Application*

EMS Operational Program*

Select

Maryland EMS Region*

Select

Company Name (if applicable)*

Principal Physical Address of the Entity*

Mailing Address (if different)

Name of Principal Contact*

Title of Principal Contact*

Email Address of Principal Contact*

Phone Number of Principal Contact*

Type of Service*

Select

Number of BLS First Response Units to be Inspected

Number of BLS Ambulances to be Inspected

Number of ALS Ambulances to be Inspected

Number of ALS Chase Car/Engines to be Inspected

Vehicle Information*

Please list unit designation by EMS/Fire Service, VIN #, license plate, make, and model for each vehicle getting inspected.

The following items must be attached to this application:

1. A list of the service's officers, titles, and levels of EMS certification or license

2. A copy of vehicle inspection certificates for each ambulance/vehicle identified for inspection

3. Proof of insurance or self-insurance for each vehicle identified for inspection

File Attachments

Drag and drop files here or

BY SUBMITTING THIS APPLICATION I (WE) HEREBY AFFIRM THAT TO THE BEST OF MY (OUR) KNOWLEDGE:

1. The fire, rescue, EMS service is qualified to provide service in Maryland and it will take such action as necessary to remain qualified during the period of certification. 2. The information given in this application is true and correct to the best of my (our) knowledge, and any fraudulent entry may be considered cause for rejection or subsequent revocation. 3. The fire, rescue, EMS service has at least one officer certified to a minimum of Maryland EMT. 4. The fire, rescue, EMS service has a sufficient complement of Maryland licensed and/or certified EMS responders to ensure the appropriate level of certified personnel for the unit being inspected (e.g., BLS ambulance - EMT; ALS ambulance - CRT-I/Paramedic) will be in the patient compartment at all times when a patient is in the ambulance.

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