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Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 1 of 2 Ambulance Company Business Permit Application REV. 10/11/22 AMBULANCE COMPANY PERMIT APPLICATION This Application is for (check one) New Permit Annual Renewal Ambulance Company Name: Business Address: Business Telephone number and Email: Legal Name of Applicant(s): Home Address: Telephone Number and Email: California Driver’s License Number and Expiration Date: Social Security Number: If a corporation, please list the names and business addresses of all directors, officers, shareholders, partners, employees or other individuals who are financially interested in the proposed operation of the ambulance business or who are involved, or proposed to be involved, directly or indirectly, with the management of the business: The number of ambulances for which a permit and license is desired to operate in Palmdale: If the business is advertised to the public and operates under a name other than the name of the applicant, please list such other name: The names, addresses and telephone numbers of at least two individuals who may be contacted by the City in case of an emergency: ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 2 of 2 Ambulance Company Business Permit Application REV. 10/11/22 OTHER REQUIREMENTS: 1. A description of any and all judgments awarded against the applicant in all cases arising out of the applicant’s operation of an ambulance service in any other jurisdiction; 2. The model, age, condition and patient capacity of each ambulance to be used in the operation of the ambulance business, and a description of the premises which are to serve as the base of operations; 3. The kind and amount of automobile liability, public liability, professional liability, worker’s compensation, and other insurance carried by the ambulance operator; 4. The color scheme and insignia to be used to identify the applicant’s ambulance; 5. The applicant’s experience in transporting sick, convalescent or injured persons; and 6. The schedule of rates to be charged by the applicant. CONDITIONS OF APPROVAL: 1. The applicant must be financially responsible and under efficient management; 2. The applicant is, under normal conditions, equipped to serve the public adequately; 3. The applicant has presented evidence sufficient to justify that the public health, safety, welfare, and convenience warrant operation of the ambulance service within the specified operating area. 4. Insurance Requirements - Every applicant for an ambulance operator’s permit shall obtain and maintain in full force and effect general liability insurance and comprehensive automobile liability insurance in conformance with Section 5.04.240. The liability coverage shall be in the amount of $1,000,000. I declare under penalties of perjury that this application is true and correct to the best of my knowledge and belief. Signature Title Date OFFICE USE ONLY Recommend ( ) Not Recommended ( ) Los Angeles County Sheriff’s Department: Signature Date Planning Manager: Signature Date