Company Register


1. Download, Sign and email us the Consent for Release of Information Release of Liability.

Consent for Release of Information Release of Liability

Please Download, Sign, and Email us:

2. Attention: To better serve you, Please do not forget to submit required documents
Click the Buttons to upload corresponding files(2MB Max). If you can't see the Button, please install Adobe flash HERE
Click to upload your W9 form Click to upload Insurance Policy Click to upload your License
3. Fill the Form.    
* (required)
Company Name *
Physical Address:
Street Address *
City *
County *
Zip *
Mailling Address:
Same as Physical Address
Street Address *
City *
County *
Zip *
Phone *
- -
Fax: - -
Cell Phone - - (sms)    
Email *
Which of the following best describes your company?
Name of Person Authorized to Enter Company Into Contractual Obligations:
Name: Title:
Phone: Fax: Email:
In what State do you operate? How many Vehicles do you operate in state?
ADD the ZIP codes of ALL the areas in which you provide transportation services(Important).
(input and click button for each 5-digital ZIP code to add,ZIP code only)
How many vehicles do you operate by type(Total must equal number above)? Please fill the number below:
Sedan-Non Taxi: Taxi:
Full Size Van: ADA Wheelchair Van:
BLS Ambulance: ALS Ambulance:
Mini Van: Non_emergency Stretcher/Gurney:
How many drivers do you employ: How many office personnel: other?
Select services that your company provide:
Please describe your hours of operation:
  Hours of Operation
Monday: Tuesday:
Wednesday: Thursday:
Friday: Saturday:
What type of 2-way communication system do you use to talk to your drivers?
Please describe your routing and dispatch technology and procedures:
Please describe your vehicle insurance coverage limits:
Do you currently provide Non-Emergency Medical Transportation(NEMT) Services?
Please list all local state or other licenses you hold.
Are you licensed as an ambulance service?
Have you ever been terminated from a State/Federal program or convicted of Medicaid/Medicare fraud?
Approximately how many WEEKLY MEDICAL trips do you currently provide?
If you would like to increase this amount,what number of weekly trips would you like to provide?
How many aditional vehicles would you need to manage that level of operation?
Are you able to offer services in a language other than English? If yes, please indicate the language:
If you currently provide NEMT services, please list the facilities you currently serve.
Please describe your dirver hiring and screening process:
Please describe your driver training and evaluation process:
What steps do you take to monitor and ensure the timeliness, safety, and sensitivity of your transportation services?
If your company qualifies, or is certified as one of the following please check the appropriate box and complete the attached DWMBE questionnaire.
Type Check Designation Ownership Definition
SBE Small Business Enterprise Business with less than 500 employee
MBE MBE Disadvantaged Business Business with 51% or more certified defined US minority ownership
WBE Woman Owned Business Enterprise Business with 51% or more certified woman ownership
VET Veteran Business Enterprise Business 51% or more certified US military veteran owned
DVBE   Disabled Veteran Business Enterprise Business 51% or more certified disabled US veteran owned
DBE Disabled Business Enterprise Business 51% or more certified disabled persons owned
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