Victorian Consolidated Regulations

NON-EMERGENCY PATIENT TRANSPORT REGULATIONS 2016 - SCHEDULE 1

Schedule 1—Application for approval in principle to operate a non-emergency patient transport service

Regulation 23(1)

APPLICATION FOR APPROVAL IN PRINCIPLE TO OPERATE A NON-EMERGENCY PATIENT TRANSPORT SERVICE

SECTION A

    (1)     Full name of applicant:

    (2)     Postal address of applicant:

    (3)     The name, telephone number and email address of a contact person for the purposes of the application:

    (4)     If the applicant is a body corporate, the name and address of a director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

SECTION B

    (1)     The name (or proposed name) of the non-emergency patient transport service, its street address and the municipal district in which the service is, or is to be, located:

    (2)     This application is for an approval in principle for a non-emergency patient transport service intending to undertake—

∗     transport of low acuity patients;

∗     transport of medium acuity patients;

∗     transport of high acuity patients.

    (3)     The proposed number and types of vehicles:

Type of vehicle	Number of vehicles
Vehicle used to transport a patient on public roads
Fixed wing aircraft
Rotary wing aircraft

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*Delete if inapplicable.

Sch. 2 substituted by S.R. No. 148/2021 reg. 31.