Request For EMS Coverage

Please provide the following information:

Organization Requesting EMS Coverage:	*
Person/Title Requesting the Stand By:	*
Phone #:	*      Fax #:
E-mail (optional):
Date of Stand By:	* Start Time: *     End Time: *
Location of Stand By:	*
Reason For Stand By:	*
Contact Person at the Stand By:	*

Choose one of the following options:*

One EMT                           $30/hr
Two EMT's & Ambulance      $60/hr
Other:

Please provide the following billing information:

Name:	*
Title:	*
Organization:	*
Street Address:	*
Address (cont.):
City:	*
State:	*
Zip Code:	*

*Required