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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 MANAGERS PERMIT APPLICATION This Application is for (check one) New Permit Annual Renewal Legal Name of Applicant: (List any other name used by the applicant) Home Address: Phone Number and Email: California Driver’s License Number and Expiration Date: Social Security Number: Business Name: Business Address: Business Telephone Number: Applicant’s last two previous addresses: The business, occupation, or employment record of the applicant for the last three years: The height, weight, hair, and eye color of the applicant: A statement as to whether the applicant has ever been convicted of any crime, misdemeanor, or violation of any municipal, state or federal law, except minor traffic violations. The nature of the offenses, and the punishment or penalty assessed therefore: ---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. Livescan fingerprinting and photo to be taken at the City of Palmdale Human Resources. 2. Los Angeles County Sheriff’s Dept Detail Personal Information Form. 3. The endorsement of the owner of the business for which the applicant will be operating as a manager. I declare under penalties of perjury that this application is true and correct to the best of my knowledge and belief. Signature of Applicant Date Signature of Business Owner Date OFFICE USE ONLY Recommend ( ) Not Recommended ( ) Los Angeles County Sheriff’s Department: Signature Date Planning Manager: Signature Date