4766-5-02 Application for initial or renewal licensure.

An applicant shall complete the application in the English language.

(A) An AMSO applying for licensure shall file with the board an application on the form prescribed by the board and shall submit the completed application to the board accompanied by the appropriate fee as defined in rule 4766-5-03 of the Administrative Code.

(B) In addition to the requirements set forth in section 4766.04 of the Revised Code, for each application the AMSO applicant shall provide:

(1) The name of applicant to include:

(a) All names that applicant plans to operate under including but not limited to trade name(s), dba(s), registered with the Ohio secretary of state;

(b) Address of AMSO's headquarters;

(c) Mailing address of applicant;

(2) All medicare provider numbers, all medicaid providers numbers;

(3) Type of organization and geographical service areas including county and state;

(4) A list of the names and addresses of all officers, directors, and/or owners of the AMSO;

(5) The name, address and physician license number of Ohio program medical director as specified in rule 4765-1-01 of the Administrative Code;

(6) For each satellite base, the AMSO shall provide the street address, city, county, state, and zip code;

(7) The name of the primary contact person, business or administrative office telephone number, and if applicable, office fax number and e-mail address;

(8) Year of manufacture, make, model, aircraft hours on airframe, and tail number;

(9) A color photograph of the side of the aircraft 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 encouraged.);

(10) A current certificate of liability insurance listing OMTB 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;

(11) Type of entity, including but not limited to, corporation, partnership, and sole proprietorship as registered with the Ohio secretary of state.

(C) Each AMSO shall pay the appropriate fees as specified in rule 4766-5-03 of the Administrative Code.

(D) If an application for licensure is incomplete, the board will notify the AMSO that the application will not be processed until it is complete. Such notification will occur via certified mail one time for each submission.

(E) The certificate of licensure issued by the board shall indicate the highest level of service that the AMSO is authorized to provide.

(F) No applicant or licensee shall submit false statements in order to obtain a license or permit.

(G) A license is not transferable.

Effective: 07/02/2009
R.C. 119.032 review dates: 07/02/2014
Promulgated Under: 119.03
Statutory Authority: 4766.03
Rule Amplifies: 4766.03 , 4766.04 , 4766.07