VENDOR PARTNER APPLICATION

Vendor Partner Type

Vendor Partner Type Commercial Independent
Personal Information
Name Name First Last
Contact Information
Email Address
Contact Phone Number Contact Phone Number - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Office Phone Number Office Phone Number - ### - ### ####
Cell Phone Number Cell Phone Number - ### - ### ####
Alternate Phone Number Alternate Phone Number - ### - ### ####
Fax Phone Number Fax Phone Number - ### - ### ####
Federal Tax ID
All applications must include a completed W9
W9 File Upload

Attach Files
Hours of Operation
Monday to Friday
Saturday and Sunday
After Hours Contact
Name Name First Last
Email
Check all Transportation Services that apply
Ambulatory- Sedan Ambulatory- Van Ambulatory- SUV Wheelchair Ambulance- ALS Ambulance- BLS Air Ambulance
Check all Translation Services that apply
In Person Translation – Medical In Person Translation – Legal Document Translation
Coverage Area: You may list zip codes, cities, counties, individual states or nationwide.
Transportation Rates
Ambulatory/Taxi
Wheelchair
Non-Emergency Stretcher
Stretcher
Ambulance: ALS
Ambulance: BLS
Other
Transportation Details
Driver's License Number
Upload Scanned Driver’s License

Attach Files
Insurance Information
Insurance Carrier
Expiration Date Expiration Date / MM / DD YYYY
Upload Certificate of Insurance

Attach Files
Vehicle Info
Vehicle Make
Vehicle Model
Vehicle Color
Translation Rates
In Person Medical
In Person Legal
Document Translation
Additional Information
Email Address

VENDOR PARTNER APPLICATION

VENDOR PARTNER APPLICATION

Personal Information

Contact Information

All applications must include a completed W9

Hours of Operation

After Hours Contact

Check all Transportation Services that apply

Check all Translation Services that apply

Transportation Rates

Ambulatory/Taxi

Wheelchair

Non-Emergency Stretcher

Stretcher

Ambulance: ALS

Ambulance: BLS

Other

Transportation Details

Insurance Information

Vehicle Info

Translation Rates

In Person Medical

In Person Legal

Document Translation

Additional Information