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Get and Sign Oems Form 500 1 8 2011-2022
Phone
Number
(
Zip
24 Hour Access Number, Non 911
E-mail address
(
)
24 Hour Access Fax Number
)
(
)
8) PARENT or ASSOCIATED COMPANIES OF OWNER
Name
Address
City
State
9) Service Ownership Type?
Sole Proprietor
Government
Zip
Partnership Corporation
Limited Partnership
Other:
10) Is this service operated by a state agency?
YES
NO
11) Level of License applying
BLS
Intermediate
Paramedic
12) with which hospital(s) do you have an affiliation agreement or memorandum of...
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FAQs
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