Victorian Consolidated Regulations

NON-EMERGENCY PATIENT TRANSPORT REGULATIONS 2016 - SCHEDULE 3

Schedule 3—Application for a non‑emergency patient transport service licence

Regulation 25(1)

APPLICATION FOR A NON‑EMERGENCY PATIENT TRANSPORT SERVICE LICENCE

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 any director or officer of the body corporate who may exercise control over the non-emergency patient transport service:

SECTION B

    (1)     The class of non-emergency patient transport for which a licence is sought—

∗     transport of low acuity patients;

∗     transport of medium acuity patients;

∗     transport of high acuity patients.

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

    (3)     The proposed number and types of vehicles:

Type of vehicle	Number of vehicles
Sedan, hatchback or station wagon vehicle
Double stretcher vehicle
Single stretcher vehicle
High acuity transport vehicle
Type of vehicle	Number of vehicles
Wheelchair vehicle
Fixed wing aircraft
Rotary wing aircraft

Signature of applicant:

Name of each signatory (in BLOCK LETTERS):

Date:

*Delete if inapplicable.