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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 1 Ambulance Driver/Attendant Business Permit Application REV. 10/11/22 AMBULANCE DRIVER/ATTENDANT PERMIT Legal Name of Applicant: Home Address: Home Telephone Number and Email: California Driver’s License Number and Expiration Date: Social Security Number: Ambulance Company: Business Address: Business Telephone number: The ambulance operator’s proposed service area: PLEASE ATTACH A COPY OF THE FOLLOWING INFORMATION: • A photocopy of a valid California Special Driver’s Certificate. • A photocopy of either an Emergency Medical Technician I or IA or II Course Completion Certificate issues by the County of Los Angeles or a certificate for an Emergency Medical Technician-Paramedic issued by the Director of Health Services, unless the applicant is a physician or registered nurse licensed by the State of California, in which case, we need a copy of the state license. 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 Dept: Signature Date Planning Manager: Signature Date