Form Dh 1576 - Application For Air Ambulance Permit - Florida Department Of Health

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
EMERGENCY MEDICAL SERVICES PROGRAM
APPLICATION FOR AIR AMBULANCE PERMIT
PROVIDER ID# _____
NAME OF SERVICE
ADDRESS
PHONE (
)
CITY
COUNTY
ZIP CODE
1.
TYPE OF APPLICATION
2.
TYPE OF PERMIT REQUESTED
A)
New
A)
Prehospital(PH)
B)
Renewal
B)
Interfacility(IF)
C)
Duplicate
1. Fixed Wing
2. Rotor Wing
C)
Both PH and IF
3.
AIRCRAFT DATA
Make
Model
Year
FAA#
Permit #
4.
Attach a copy of FAA Part 135 certificate (all of parts A and D included). If name of certificate
holder is not the applicant, include a letter of agreement or contract between the applicant and
the Part 135 certificate holder for the aircraft listed on this application.
5.
Attach a copy of the air worthiness certificate.
6.
Enclose permit fee - PLEASE DO NOT SEND CASH. Checks should be made payable to
Emergency Medical Services and mailed to 4052 Bald Cypress Way, Bin C-30, Tallahassee, FL
32399-1738.
ALL FEES ARE NONREFUNDABLE. § 401.34(1) Fla. Stat.
I, the undersigned representative of the above firm, do hereby affirm that the above described
aircraft will be staffed, equipped and medically supplied and that all equipment and medical
supplies will be in good working order, during patient transport, in accordance with Chapter
395 and 401, Fla. Stat. and Chapter 64J-1, Fla. Admin. Code. I also affirm that this aircraft
meets and is maintained in accordance with all FAA requirements as documented in “4” above.
Documentation of all crew member qualifications are included with DH Form 1575 Air
Ambulance License Application.
NAME (PRINTED)
POSITION
SIGNATURE
DATE
FALSE OFFICIAL STATEMENTS: § 837.06, Fla. Stat.: Whoever knowingly makes a false statement
in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of
a misdemeanor of the second degree.
DH 1576, 04/09
Incorporated by reference 64J-1.005

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