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Organizaton Trade Name (DBA):*

Official Organizaton or Parent Company Name

Organization Address*

Street Address Address Line 2 City State ZIP Code

Website

Organization Representation

Please designate your primary and alternative representative who will be the point of contact and who may cast a vote on your organization's behalf

Primary Representative*

First Last

Primary Rep Email*

Primary Contact Phone*

Alternate Representative

First Last

Alternate Rep Email

Altrernate Phone

Organizational Structure

Formal Organization*

Tax Status*

Ownership Information: Corporations, Partnerships, Sole Proprietorships

Corporate Ownership

Owner / Officer 1

First Last

Title

Location

Primary business location

Owner / Officer 2

First Last

Title

Location

Primary business location

Owner / Officer 3

First Last

Title

Location

Primary business location

Service Information

Number Of TDSHS Licensed Units*

Service Level*

MICU
ALS
BLS
SCT
Rotor Wing
Fixed Wing

Mark all that apply

Service Type*

911 Provider
Emergency
Non Emergency
Scheduled Transports

Mark all that apply

Staff Type*

Paramedic
Intermediate / Advanced
EMT
Nurse

Mark all that apply

Hours of Operation

24/7/365
Business Hours
Modified Hours

Dispatch Type*

Internal
PD / SO
Regional Call Center

Dispatch Phone*

Direct Dial Number (Not 911)

Service Area

Please provide us with your primary response area(s) to include City, County or geographical locations.

City(s) Served*

County(s) Served*

Geographic Area

RAC Participation

Please list the RACs your organization participates in

State /National Response Agreements

EMTF MOU
FEMA
Regional Mutual Aide

Mark all that apply

Membership Application

Organization Representation

Organizational Structure

Ownership Information: Corporations, Partnerships, Sole Proprietorships

Service Information

Service Area