Medical Rescue Agency Certification
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1
2APPLICATION – MEDICAL RESCUE AGENCY CERTIFICATION
STATE OF NEW MEXICO - EMERGENCY MEDICAL SYSTEMS BUREAU
PLEASE TYPE or PRINT. APPLICATION MUST BE NOTARIZED.
Renewal
New Application
Application
Service Number
Date
Indicate the county in which you wish to certify and the number of Medical Rescue units to be inspected.
County
Number of units
Please attach a Company Check, Money Order or Purchase Order to each application. Fee structure listed below (Initial and
Renewal).
EMS Agency
Up to 3 Vehicles -$100.00
Special Event EMS -
$ _____
*Late Fee
$100.00
+$_____
(Postmarked or
(Transport
4-10 Vehicles - $150.00
+$_____
hand-delivered after
Capable Medical
th
Rescue and Non-
Emergency Medical
January 15
; 25%
Transport Medical
More than 11 Vehicles- $200.00
Dispatch - $100.00
=______
increase over the
Rescue):
Primary Fee
Company name (owner/parent company)
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
Doing Business As (dba)
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
NM Medical License
Medical Director
Number
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
Facility Affiliation
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
Director/Chief or individual responsible for operation of
Name
service:
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
Dispatch Center
Address
City
State
Zip Code
Telephone number
Fax number
E-Mail
NMDOH EMSB MEDICAL RESCUE/CBecvarik Master/ADMIN APP-DOC
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