(A) An ambulette service applying for licensure shall file with the board an application on the form prescribed by the board, as published on the board's website at http://omtb.ohio.gov/Forms/Form2.pdf, dated April 16, 2012, in the English language, and shall submit the completed application to the board accompanied by the appropriate fee as defined in rule 4766-3-03 of the Administrative Code.
(1) The name, organizational structure and address of applicant as follows:
(b) Identification of organizational structure as a corporation (whether for profit or not-for-profit); limited liability company; partnership; limited liability partnership; government unit; or sole proprietor (individual human);
(c) All other names under which applicant plans to operate;
(d) Copies of all trade name registrations and fictitious name registrations for all other names under which applicant plans to operate on file with the Ohio secretary of state;
(e) Address of physical location of applicant's headquarters (no post office box);
(f) Mailing address of applicant;
(2) All medicare provider numbers, all medicaid provider numbers, if applicable;
(3) Service areas including county and state;
(4) The street address, city, county, state, and zip code for each satellite base;
(5) The name of the primary contact person, business or administrative office telephone number, and if applicable, office fax number and e-mail address of applicant;
(6) Names of all officers, directors, and/or owners of applicant;
(7) Year of manufacture, make, model, vehicle identification number, odometer reading, license plate number (renewal only) of each ambulette applicant seeks to be permitted;
(8) A color photograph of the side of applicant's ambulette displaying color scheme, insignia, monogram, or other distinguishing characteristic. If multiple color schemes, insignias, monograms, or other distinguishing characteristics are used, a color photograph of each must accompany application. (Digital photographs are preferred.);
(9) A current certificate of liability insurance in the name of applicant, listing Ohio medical transportation board as a certificate holder with a thirty day cancellation notice as specified in section 4766.06 of the Revised Code;
The actual name on the licensure application shall appear on the certificate of liability insurance;
(D) If an application for licensure is incomplete, the board will notify the applicant that the application will not be processed until it is complete. Such notification will occur via certified mail one time for each submission.
(E) No applicant or licensee shall submit false statements in order to obtain a license or permit.
(F) A license is not transferable.