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TYPE OF BUSINESS Check one of the following definitions which applies to your business:
1. First aid vehicle: Any motor vehicle for hire that is constructed, equipped or regularly
provided for the transportation in the sitting or non-recumbent position of persons, and in
connection therewith the rendering of first aid care as defined in Eugene Code Chapter 3.
2. Medical transport vehicle: Any motor vehicle for hire that is constructed, equipped or
regularly provided for the transportation in the sitting or non-recumbent position of non-
ambulatory or medically impaired persons not requiring ambulance services as defined in
Eugene Code Chapter 3.
3. Limousine: an unmarked luxury class motor vehicle that is operated for hire on a reserved,
hourly basis, and used on a prearranged basis for special or business functions, weddings,
funerals or similar purposes.
Describe the services that you intend to provide:
What geographical area will you serve?
Name of your insurance carrier: _______________________ Policy number: ________________
Name and phone number of insurance agent:
Registered Agent
_________________________
Name Phone
Street Address City Zip
Attach a photo of each vehicle and a rate sheet.
APPLICANT'S STATEMENT
Applicant agrees to defend, indemnify, and hold harmless the City of Eugene, its officials, agents,
and employees for all claims of injury to property or persons that may arise as a result of any
activity carried on by the registrant.
I have read and understood the regulations that pertain to my business. My company is in full
compliance with all laws, rules, and regulations. I will notify the city, in writing, within 10 days if
there are any changes in the information provided on this form.
_________________________
Signature of owner or business manager Date
