AMBULANCE DRIVER’S PERMIT APPLICATION
City of Houston
Department of Health and Human Services
Permit Number: |
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Paid: |
IMPORTANT NOTICE
All questions in this application must be answered completely. Providing false information constitutes perjury
and will cause the permit to be denied, or if granted, revoked. Processing fee is not refundable.
Application must be typed or completed electronically. Handwritten applications will not be accepted.
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FULL NAME: |
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CURRENT ADDRESS: |
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CITY: |
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STATE: |
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ZIP: |
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DOB: |
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TDL NUMBER: |
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EXPIRATION: |
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HOME PHONE NUMBER: |
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DAYTIME PHONE NUMBER: |
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SEX: |
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HEIGHT: |
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HAIR COLOR: |
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EYE COLOR: |
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TSHS EMT PERSONNEL ID NUMBER:
1.For what company do you work? Company Phone Number:
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2. |
Have you ever been denied an Ambulance Driver’s Permit? |
Yes |
No |
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If “Yes”, explain: |
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Have you ever had your Ambulance Driver’s Permit suspended or revoked? |
Yes |
No |
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If “Yes”, explain: |
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In consideration of the granting of the permit hereby applied for, the applicant agrees that service of all papers, notice, letter, summons, complaint or legal process of any kind or nature may be made by the City of Houston, or any Department thereof, wherein the person to whom the permit is named, may be issued by leaving a copy of any such paper, notice, letter, summons, complaint, or legal process or any member of his family or other persons with whom he/she may reside. It is further agreed by the applicant that he/she will conform to all rules and regulations of Houston Department of Health and Human Services, governing ambulance drivers.
AFFIDAVIT
State of Texas |
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County of |
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, being duly sworn, on his/her oath deposes and says that he/she is the individual making the foregoing application for an Ambulance Driver's Permit; and, that the answers to the foregoing questions and other statements contained therein are true of his/her own knowledge.
Sworn to and subscribed before me this |
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Signature of Notary |
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Signature of Applicant |
Notary Public, State of Texas |
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My Commission Expires |
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Houston Department of Health and Human Services
EMS Program
INSTRUCTIONS
AMBULANCE DRIVER’S PERMIT APPLICATION
1.0Requirements
1.1Applicant must be 18 years of age or older.
1.2Applicant must submit a photocopy of his/her Texas Driver’s License.
1.3Applicant must submit photocopies (front and back) of a valid Texas Emergency Medical Technician Certificate.
1.4Applicant must have the application notarized. Note: The City of Houston EMS Program does not
provide notarization.
1.5Applicant must submit a non-refundable $128.23 processing fee which includes a $25 administrative fee with the application, payable to the CITY OF HOUSTON only by Personal Check, Company Check (with pre-printed company name, address and telephone number), Cashier’s Check or Money Order. Permits will not be processed or issued without payment of fee. Applications will be processed when the requirements of Section 1.0 are met.
1.6Applicant must submit his/her Original Three Year Certified Motor Vehicle Record from Texas Department of Public Safety for review.
1.7Applicant must submit the EMS Program Affidavit signed by the employer (owner/manager of the Ambulance Company), which states that the applicant’s Motor Vehicle Record, dated within
60 days of the affidavit, was reviewed by the owner/manager of the Ambulance Company and found to comply with the March 1st, 2008, City of Houston Ambulance Driver Motor Vehicle Record Requirements.
1.8Applicant must not have any pending violation(s) related to the City of Houston Ambulance Ordinance.
2.0Application Processing Procedures
2.1Applications must be typed or completed by computer and notarized no more than thirty (30) days prior to the date received. Handwritten applications will not be accepted.
2.2Only complete and notarized applications will be processed.
2.3Submission of the application
2.3.1Applying in person – Submit the above documents at the office of the EMS Program between the hours of 8:00 am -12:00 pm and 1:00 pm - 4:00 pm, Mon-Fri.
2.3.2Applying by mail – Mail the above documents to the address at the bottom of this form.
2.4Please allow two weeks from the date your completed application is received at the EMS Program Office for processing.
2.5If the application is approved, the permit will be mailed to the address provided on application. If the permit is not approved, a letter explaining the reason(s) will be mailed to that same address.
3.0Permit Requirements
3.1The Ambulance Driver’s Permit shall be valid for two years.
3.2NO GRACE PERIOD IS GIVEN FOR EXPIRED PERMITS. Renewal application must be submitted at least two weeks before the expiration date of a Driver’s Permit and must comply with requirements in Section 1.0 above.
3.3Applicants must be in physical possession of a City of Houston Ambulance Driver’s Permit before he/she can transport a patient in Houston.
These instructions and the Ambulance Driver Permit Application are available in electronic form at the web
address: http://www.houstontx.gov/health/EMS/index.html
Houston Department of Health and Human Services-EMS Program
7411 Park Place Blvd., Suite 200
Houston, TX 77087 832-393-5611
Ver. 1/11
City of Houston
Emergency Medical Services (EMS) Program
Ambulance Driver Motor Vehicle Record Requirements
January 1, 2011
Applicants seeking an Ambulance Driver Permit from the City of Houston will be evaluated on the most recent 3-year history reflected on their Motor Vehicle Record (MVR) and Points will be assigned accordingly. If the total points equal six (6) or more for the preceding 36 months, the applicant’s permit will not be issued.
1.Type A Violations: convictions for Type A violations count as six (6) points against applicant’s Record. Type A violations are listed but not limited to the following:
•Criminal negligent homicide
•DUI, DWI, BAC, any violation related to alcohol, illegal drugs or controlled substances
•Hit and run/leaving the scene of an accident
•Fleeing from police officer
•Drag racing/speeding contest
•Aggravated assault with a motor vehicle
•Driving with a suspended/revoked driver license
•Reckless driving
•Felony use of a Commercial Motor Vehicle (CMV)
Driving Under the Influence (DUI), Driving While Intoxicated (DWI), Blood Alcohol Concentration (BAC) convictions mean being convicted, receiving a probated sentence, or pleading no contest for driving a commercial or non-commercial vehicle under the influence of alcohol, drugs or any illegal substance.
2.Type B violations: Each conviction for Type B violations counts as applicant’s record. Type B violations are all moving traffic violations violations.
two (2) points against the not listed above as Type A
Non-moving administrative offenses such as an out-dated inspection sticker, no proof of liability insurance, missing license plate, etc… are not considered Type B violations.
3.At-Fault-Accidents: Each at-fault-accident counts as two (2) points. A moving traffic violation conviction on a driving record along with an accident on the same date usually indicates the driver was at fault in the accident. If an at-fault-accident and a moving violation occur during the same incident the moving violation will count as zero (0) points.
Note: The items 1, 2, and 3 listed above are not a complete list of the Texas Department of Public Safety Moving Violations Code and are subject to change. Therefore, these items are not all inclusive and other violations may be considered when issuing an Ambulance Driver Permit.
THE STATE OF TEXAS
COUNTY OF HARRIS
AFFIDAVIT
BEFORE ME, the undersigned authority, personally appeared |
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upon being sworn, deposed and stated as follows: |
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(Owner’s/Manager’s Name) |
My name is |
I am the owner/manager of |
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(Owner’s/Manager’s Name) |
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(Name of Ambulance Company) |
at |
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(Address) |
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I have reviewed |
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(Employee’s Name) |
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Texas Motor Vehicle Record of |
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and confirm that this employee meets the |
(Date of Motor Vehicle Record)
March 1st 2008, Ambulance Driver Motor Vehicle Record requirements of the Houston Department of Health and Human Services Program and is eligible for a City of Houston Ambulance Driver’s Permit
I read this affidavit and swear that such statements contained herein are true and correct.
_________________________________
AFFIANT
State of Texas |
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County of |
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Sworn to and subscribed before me this |
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day of |
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Notary Public for the State of Texas |
My Commission Expires |
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EMS DRIVER’S PERMIT
DO YOU HAVE THESE?
1.An affidavit signed and completed by your employer and notarized within the past 30 days.
2.A certified original Motor Vehicle Record (MVR) dated within the previous 60 days.
3.A complete notarized driver’s application form.
4.A copy of your valid Texas Driver’s License.
5.A copy of your valid Texas Department of State Health Services Emergency Medical Technician Card.
6.A Personal Check, Company Check, Cashier’s Check or Money Order in the amount of $128.23
7.An application form completed and notarized within the past 30 days.
January 1, 2012
