Maine Ems Service License Application Sheet For Renewal
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3PO #/Amount: ___________
Check #/Amount: ___________
MAINE EMS SERVICE LICENSE
APPLICATION FOR RENEWAL
Section I – Service Information
A. Service Name: _________________________________
Service #: __________
Expiration Date: ____________
Mailing Address: _______________________________
Shipping Address: ______________________________
City: __________________ State: ______ Zip: _______
City: __________________ State: ______ Zip: _______
B. Business Telephone #: _______________________
Fax #:_______________________
E-Mail Address: _____________________________________________________________
D. Physical address of bases used by this service
1. Street: _______________________________________________
City: __________________ State: ______ Zip: _______
Telephone #: _______________________
Fax #: _______________________
Base Primary Contact: ___________________________________________
2. Street: _______________________________________________
City: __________________ State: ______ Zip: _______
Telephone #: _______________________
Fax #: _______________________
Base Primary Contact: ___________________________________________
3. Street: _______________________________________________
City: __________________ State: ______ Zip: _______
Telephone #: _______________________
Fax #: _______________________
Base Primary Contact: ___________________________________________
4. Street: _______________________________________________
City: __________________ State: ______ Zip: _______
Telephone #: _______________________
Fax #: _______________________
Base Primary Contact: ___________________________________________
Section II – Service Administration
List the names and telephone numbers of the service administration. (Note: this list will supersede all previous lists).
1. 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: ______________________
2. 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: ______________________
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