Transportation Provider Application

Business Information

Transportation Provider Name* Official name used in your provider contracts, if applicable. Provider Company Website Public-facing URL (include https://). Business Name* Legal or doing-business-as name. Address* Street, City, State, ZIP. Business Start Date* How long has your transportation service been in operation?

Contact Information

First Name* Primary point of contact. Last Name* Surname / family name. Job Title* Role within the company.

Email* Phone Number* Fax Number

Owners (optional)

Owner 1 NameFirst Name, Last Name Owner 2 NameFirst Name, Last Name Owner 3 NameFirst Name, Last Name Owner 4 NameFirst Name, Last Name

Business Details

NPI Number If applicable. Tax ID Number EIN / TIN.

Dispatch Software* TP Software

Description of Services Offered*

Ambulance - Advanced Life Support

Ambulance - Basic Life Support

Stretcher

Wheelchair/Ambulette

Ambulatory (sedan/black car/cab)

Bus

Bus - Deviated Fixed Route/Demand Response

Days and Hours of Operation e.g., Mon–Fri 7am–6pm; Sat 8am–2pm

Service State (Primary)* Choose your primary service state. Base County* County of primary base. Service State (Secondary) Optional. Secondary Base County Optional.

Secondary State Counties of Service or Service Area Description List counties or describe your coverage area.

Languages Spoken

English Spanish Russian Hmong Mandarin Arabic Vietnamese Other

Liability, Certifications & Consents

Insurance Details

Comprehensive General Liability (CGL) Coverage Amount Sexual Abuse Molestation (SAM) Coverage Amount Automobile Insurance (Combined Single Limit)* Workers’ Compensation Coverage Amount* General Liability (Aggregate Amount)*

Upload Certifications

PASS Wheelchair Certificate PDF/JPG/PNG up to 10MB. First Aid/CPR Certification PDF/JPG/PNG up to 10MB. Defensive Driving Certificate PDF/JPG/PNG up to 10MB.

Consents* I consent to pass a Drug Screening as a condition of participation. I consent to a Motor Vehicle Report (MVR) check. I consent to a Background Check.

Please share your most recent certification dates, if applicable

Date Certified as Minority Owned Business Enterprise (MBE) Date Certified as Historically Underutilized Business (HUB) Date Certified as Woman Owned Business Enterprise (WBE) Date Certified as Disadvantaged Business Enterprise (DBE) Date Certified as Disabled Veteran Enterprise Airport Concessions Disadvantaged Business Enterprise (ACDBE)

Review & Submit

Please review your information below. If everything looks correct, submit your application.