State of Ohio EMS
Licensed Medical Transportation ProviderAttestation FormI, the undersigned as the authorized representative of _________________________________ Medical Transportation Servicedo hereby attest that, in order to temporarily (please check all that apply):??Obtain a new license??Renew my existing license ??Add a vehicle ??Add a satellite station ??Change my headquarters address ??Change my level of service during this Declared State of Emergency, I have complied with the temporary requirementestablished by the Division of EMS as follows (please check all that apply):??Completed and signed an inspection form for my headquarters location ??Completed and signed an inspection form for satellite location(s), if applicable??Completed and signed an inspection form for medical transportation vehicles VIN(s) ________________________________________________________________________Inspection forms are to be kept on file with the medical transportation service.________________________________ ________________________________ Signature Date________________________________ Printed Name Send completed attestation forms to the Division of EMS, Attn: Medical Transportation Section.Fax: 614 466-9461, E-mail: emsmedicaltransportation@dps. , Mail: Ohio Division of EMS1970 W. Broad St. Columbus, OH 43223 ................
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