Private Ambulance and Transport Registration

All Ambulance Service Operators providing non-emergency transports within the municipal boundaries of the City of Oshkosh shall register with the City. Registrations shall be filed with the City Clerk's office. The Clerk shall maintain the Registrations with the official records of the City, and shall transmit copies of all Registrations, including any supporting documents, to the Fire Chief. The Fire Chief or their designee shall have the authority to enforce the requirements of this Section. There shall be no charge for filing the the Registration with the City.

1. Registrant Contact Information:

Full Name

Full Name is Required

Address
Address is Required

City
City is Required

State
State is Required

Zip Code
Zip Code is Required

Business Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 Business Phone is Required

After Hours Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 After Hours Phone is Required

Business Email
You must enter in a valid email address Business Email is Required

2. Registrant's Agent Contact Information. One primary and secondary agent are required.

Primary Agent Full Name
Primary Agent Full Name is Required

Address
Address is Required

City
City is Required

State
State is Required

Zip Code
Zip Code is Required

Business Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 Business Phone is Required

After Hours Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 After Hours Phone is Required

Business Email
You must enter in a valid email address Business Email is Required

Secondary Agent Full Name
Secondary Agent Full Name is Required

Address
Address is Required

City
City is Required

State
State is Required

Zip Code
Zip Code is Required

Business Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 Business Phone is Required

After Hours Phone
You must enter phone number as (555) 555-5555 or 555-555-5555 After Hours Phone is Required

Business Email
You must enter in a valid email address Business Email is Required

3. If Registrant is an entity, identify the state of formation.

Entity is Required

4. All trade or other corporate names, if any, under which the Registrant does business or proposes to do business.

Corporate Names is Required

5. A copy of all licenses and/or certificates issued by the State of Wisconsin Department of Health Services or other regulatory body that the Registrant believes enables it to lawfully perform the proposed services within the City of Oshkosh.

6. Signature of the Registrant or the Registrant's authorized representative.

Digitally sign
Digital Signature is Required

Date
Date Signed is Required