Ambulance Personnel Permit Application
IMPORTANT NOTICE
All Questions in this application must be answered completely. Providing false information constitutes perjury and will cause
the permit to be denied, or if granted, revoked. Processing fee is not refundable.
Application must be typed or completed electronically. Handwritten applications will not be accepted.
Full Name
Current Address, City, State, ZIP:
DOB: TDL No. Expiration:
Home Telephone No. Daytime Phone No.
Gender: Height: Hair Color: Eye Color:
TDSHS EMS Personnel ID Number:
For what company do you work for? Company Phone No.
Have you ever been denied an Ambulance Personnel Permit? YES NO
If “YES”, Explain:
Have you ever had your Ambulance Personnel Permit suspended or revoked? YES NO
If “YES”, Explain:
In consideration of the granting of the permit hereby applied for, the applicant agrees that service of all papers, notice, letter,
summons, complaint or legal process of any kind or nature may be made by the City of Texas City, or any Department therof,
wherein the person to whom the permit is named, may be issued by leaving a copy of any such paper, notice, letter, summons,
complaint, or legal process or any member of his family or other persons with whom he/she may reside. It is further agreed by
the applicant that he/she will conform to all rules and regulation of the Texas City Fire Department, governing ambulance
personnel.
AFFIDAVIT
State of Texas, County of _______________§
_________________________________, being duly sworn, on his/her oath deposes and says that he/she is the individual
making the foregoing application for an Ambulance Personnel Permit; and, that the answers to the foregoing question and other
statements contained therein are true of his/her own knowledge.
Sworn to and subscribed before me this _____________ day of _____________________, 20___________.
Signature of Notary Signature of Applicant
Notary Public, State of Texas
My Commission Expires
Texas City Fire Department
1725-25
th
Street North
Texas City, TX 77590
(409) 643-5705
Received Date:
Amount Paid:
Issue Date:
Expired Date:
