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 Registration with the City.

1. Registrant Contact Information

Full Name

Address

City

State

Zip Code

Business Phone

After Hours Phone

Business Email

2. Registrant's Agent Contact Information.

One primary and secondary agent are required.

Primary Agent Full Name

Address

City

State

Zip Code

Business Phone

After Hours Phone

Business Email

Secondary Agent Full Name

Address

City

State

Zip Code

Business Phone

After Hours Phone

Business Email

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

4. All trade or other corporate names

If any, under which the Registrant does business or proposes to do business.

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

Date