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(A) "Ambulette Inspection" form
or form "EMS 4019" (February, 2017) can be accessed at the
division's website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(B) "Application for Ambulette License" form or form
"EMS 4002" (January, 2018) can be accessed at the division's
website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(C) "Deletion of Vehicle" form or form "EMS
4012" (April, 2016) can be accessed at the division's website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(D) "Headquarters Change of Address" form or form
"EMS 4004" (April, 2016) can be accessed via the division's
website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(E) "Periodic Mechanical Safety Report" form or form
"EMS 4039" (June, 2017) can be accessed via the division's
website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(F) "Renewal Application for Ambulette License" form or
form "EMS 4041" (May, 2018) can be viewed at the division's
website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(G) "Temporary Ambulette Application" form or form
"EMS 4010" (July, 2013) can be accessed via the division's
website at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.(H) "Violation Notification" form or form "EMS
4029" (July, 2018) is issued by the board to an ambulette
service/non-emergency medical services organization that is in violation of
Chapter 4766. of the Revised Code and agency 4766 of the Administrative Code
and can be viewed at
http://www.ems.ohio.gov/medical-transportation-forms.aspx.
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