Fillable N.C. Department of Health and Human Services (North Carolina)

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N.C. Department of Health and Human Services (North Carolina)

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N.C. Department of Health and Human Services
Division of Health Service Regulation
Offic
e of Emergency Medical Services
2707 Mail Service Center ■ Raleigh, North Carolina 27699-2707
APPLICATION TO PROVIDE HEALTH CARE SERVICES
[G.S. §90-21.100.]
Name of Sponsoring Organization:
Name and Address of Each Principal Individual (Please list the name, street address,
city, zip code and phone number of the individuals who are officers or organizational
officials responsible for the operation of the sponsoring organization)
Sponsoring Organization County:
Sponsoring Organization Mailing Address:
Sponsoring Organization Telephone number:
Please be advised
, the one-time registration fee in the amount of $50.00 must
accompany the completed application and be submitted to the Division of Health
Service Regulation.
DHHS/DHSR/OEMS 4915 Effective Date 01/01/2013
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N.C. Department of Health and Human Services (North Carolina)

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Completed 21 February 2022

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