Ambulance Service Permit Application
To the Texas City Fire Department, EMS Administration: In conformity with the City Ordinance, application for an Ambulance
Service Permit is hereby submitted on behalf of the EMS Provider whose information is provided below:
Ambulance Service Full Name
TDSHS Company License Number
Mailing Address
Physical Address
Telephone No. Fax No. EMail Address
Owned by the Following person(s):
Last Name, First Name Home Address Driver License No.
Vehicle Liability Insurance Provider: Telephone No.
Policy No. Insurance Agent’s Name:
Minimum Amount per Accident $ Per Person Injured $
Medical Directory Medical License No.
Business Address
Telephone No. Fax No. EMail Address
Director of Operations or Agent responsible for the local operation of the Ambulance Service described above is:
Last Name, First Name Texas Driver License No.
Signature of Applicant
Before me, a notary public, on this day personally appeared known to me to be the person
whose name is subscribed to the foregoing applicantion and, being by me first duly sworn, declared that the statements therin
contained are ture and correct.
Given under my hand and seal of office this _____________ day of _____________________, 20___________.
Notary Public Seal Notary Public Signature
Texas City Fire Department
1725-25
th
Street North
Texas City, TX 77590
(409) 643-5705
Received Date:
Amount Paid:
Issue Date:
Expired Date:
