Victorian Consolidated Regulations

NON-EMERGENCY PATIENT TRANSPORT REGULATIONS 2016 - SCHEDULE 4A

Schedule 4A—Application for transfer of licence to operate a non-emergency patient transport service

Regulation 27A(1)

APPLICATION FOR TRANSFER OF LICENCE 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:

SECTION B

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

    (2)     The number and type of vehicles (even if no changes are proposed):

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

    (3)     In relation to the person to whom the licence is to be transferred

        (a)     the name of that person; and

        (b)     the postal address of that person; and

        (c)     that person's telephone number and email address.

    (4)     If the proposed transferee 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:

Signature of applicant:

Name of each signatory:

Date:

Sch. 5 substituted by S.R. No. 148/2021 reg. 33.