Change In Service Administration Form

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Change in Service Administration Form
Please complete this form by listing all requested information. Then mail the form to Maine EMS. Please print legibly.
Service Name: __________________________________________ Service Number: __________ Date: ___________
DIRECTOR: ____________________________________________________________
Maine EMS License #: _______________
*
* If no EMS License, mark N/A
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required if no EMS License
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
ASSISTANT DIRECTOR: ________________________________________________
Maine EMS License #: _______________
*
* If no EMS License, mark N/A
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required if no EMS License
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
ADDITIONAL REPRESENTITIVE: _______________________________________
Maine EMS License #: _______________
*
* If no EMS License, mark N/A
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required if no EMS License
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
SERVICE MEDICAL DIRECTOR: _________________________________________ Medical License #: __________________
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
INFECTION CONTROL OFFICER: _______________________________________
Maine EMS License #: _______________
*
* If no EMS License, mark N/A
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required if no EMS License
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
PRIMARY QA/QI CONTACT: ____________________________________________
Maine EMS License #: _______________
*
* If no EMS License, mark N/A
E- Mail address: ________________________________________________________
Date of Birth: ________________
*
* Required if no EMS License
Telephone #: Home: ______________________ Work: ______________________ Cell: ______________________
I certify that the personnel listed above are Authorized Representatives of the service named herein, and that I am authorized by that service to amend
the authorized representative list. I understand that this document will supersede any and all Authorize Service Representative lists for the service.
Authorizing Signature
Print Name
Date
PHONE: (207) 626-3860
FAX: (207) 287-6251

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