Emergency Medical Service Funding Assistance Program Application 2025

1. Click ‘Get Form’ to open the Emergency Medical Service Funding Assistance Program Application in the editor.
2. Begin by filling out the 'Ambulance Service Provider Information' section. Enter your licensed provider name, provider number, complete mailing address, telephone number, Federal Employer ID Number, and email address.
3. Next, move to the 'Certification of Municipality / Contracting Agency(s)' section. Identify all municipalities in your primary service area and ensure each municipality certifies its actual population served and the percentage this represents.
4. For each municipality, input the Municipal Code, total Population Served by your ambulance service provider, and calculate the Percentage of total population represented. Ensure accuracy as this information is crucial for funding eligibility.
5. Finally, have the municipal clerk sign and date the form to certify that all provided information is true. If there are multiple municipalities, you can copy this page as needed.

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