[Comment: For dates and availability of material incorporated by reference in this chapter of the Administrative Code, see paragraph (BB) of rule 4766-5-01 of the Administrative Code.]
(A) An AMSO applying for licensure shall file with the board an "Application for Air Medical License," as appropriate, in the English language 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.
(1) The name, organization structure and address of AMSO applicant to include as follows:
(b) Identification of organizational structure as a corporation (whether for profit or non-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);
(2) All medicare provider numbers, all medicaid provider numbers;
(3) Service areas including county and state;
(4) A list of the names of all officers, directors, and/or owners of the AMSO;
(5) For each satellite base, the AMSO shall provide the street address, city, county, state, and zip code;
(6) The name of the primary contact person, business or administrative office telephone number, and if applicable, office fax number and e-mail address;
(7) Year of manufacture, make, model, tail number, and aircraft hours on airframe;
(8) A color photograph of the side of the applicant's 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 preferred.);
(9) A current certificate of liability insurance in the name of the applicant, listing state board of emergency medical, fire, and transportation services 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 shall notify the AMSO 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.
Cite as Ohio Admin. Code 4766-5-02