Transcription of Non-Emergency Transportation Vendor Application
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Non-Emergency Transportation Vendor Application
Page 1 of 5 Non-Emergency Transportation Vendor Application PLEASE CHECK THE FOLLOWING TO MAKE SURE YOU VE SUBMITTED A COMPLETE Application : 1. Have you completed all provider information? 2. Have you attached a copy of your insurance coverage? 3. Have you attached a copy of your business license? 4. Did you sign the Application ? Company Information Legal Name of Service: DBA: Corporate Street Address: City: County: State: Zip Code: Phone: Fax: E-mail: Federal Tax ID Number (or SS# if sole proprietor) Mailing Address: (if different) City: State: Zip Code: If multiple locations, please attach a separate list of all applicable service locations, addresses and contact information 1. Names of contacts for your business: Name Title Phone Email 2. Please identify the types of service you provide AND the number of vehicles you use in regular service Ambulatory Wheelchair _____ Stretchers Other: Ambulances 3.
Non-Emergency Transportation Vendor Application PLEASE CHECK THE FOLLOWING TO MAKE SURE YOU’VE SUBMITTED A COMPLETE APPLICATION: 1. Have you completed all provider information? 2. Have you attached a copy of your insurance coverage? 3. Have you attached a copy of your business license? 4. Did you sign the application? Company Information
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