New/Replacement Ambulance Information Sheet
Total Page：16
File Type：pdf, Size：1020Kb
2829 University Ave. S.E., Suite 310 Minneapolis, MN 55414-3222
(651) 201-2800 (800) 747-2011 FAX (651) 201-2812 TTY (800) 627-3529
www.emsrb.state.mn.us
AMBULANCE INFORMATION SHEET
Service Name: EMS Number:
Contact Person: Fax #:
Ambulance Location:
Is this an additional ambulance or a replacement ambulance? ADDITIONAL (see #1 below) REPLACEMENT (see #2 below) RECHASSIS (see #3 below)
1. Additional Ambulance: PLEASE go to WWW.EMSRB.STATE.MN.US and click on AMBULANCE SERVICES on the left side of the page. This will take you to your LOGIN page and you may complete this transaction, including payment, in your on- line account. A fee of $4 for each month during the period for which the decal is being issued is required only when an additional ambulance is added to your fleet ($4 x [number of months left in current licensing period] = total fee due).
2. Replacement Ambulance: Provide the following information about the ambulance which is being replaced:
Old:
VIN # Year Make Model Mileage Vehicle #
New:
VIN # Year Make Model Mileage Vehicle # 3 . Rechassied Ambulance: Provide the following information about the ambulance being rechassied:
Old:
VIN # Chassis Year Pt Compartment Year Make Model Mileage Vehicle #
New:
VIN # Chassis Year Pt Compartment Year Make Model Mileage Vehicle #
I certify that information as described above is true and correct and that the ambulance and equipment in the ambulance meet all requirements of Minnesota Statutes 144.E and Minnesota Rules Chapter 4690.
Signature of Company Officer or Legally Authorized Official Date
"To provide leadership which optimizes the quality of emergency medical care for the people of Minnesota -- in collaboration with our communities -- through policy development, regulation, system design, education, and medical direction" An Equal Opportunity Employer EMSRB – 6-2007 When the above information is received by the Minnesota Emergency Medical Services Regulatory Board, a letter of confirmation will be sent authorizing you to place the vehicle in service until an inspection can occur.
NO AMBULANCE WILL BE ISSUED A LICENSING DECAL UNTIL AN INSPECTION HAS BEEN COMPLETED AND REQUIREMENTS FOR AMBULANCE VEHICLES AND EQUIPMENT AS DEFINED IN MINNESOTA STATUTES 144.E AND MINNESOTA RULES CHAPTER 4690 ARE MET.