The applicant shall apply to the Office on forms provided by the Office. The application shall be notarized and shall include the following:

1. (a) The name, address and nature of the legal entity that will implement the proposed service;
2. (b) The name, address and telephone number of the individual responsible for making application;
3. (c) The trade name, department, corporation, association or partnership under which the provider is or shall do business. If the provider is a corporation, name, address and title of all officers;
4. (d) Name of parent and associated companies if any;
5. (e) Type of service requested;
6. (f) Locations of proposed principal place of business and/or branch places of business;
7. (g) Locations of health facilities and other ambulance providers within the proposed area to be served;
8. (h) Number and types of currently authorized vehicles;
9. (i) Number and types of new or expanded emergency medical services being requested;
10. (j) Geographic area and population to be served in implementing the proposed service;

11. (k) Source and volume of calls over the past 12 months for a currently licensed applicant;

    (l) Total number of calls a currently licensed applicant refused over the past 12 months, and the circumstances for refusal;

12. (m) Source and volume of calls expected over the next 12 months;
13. (n) Average response times over the past 12 months for a currently licensed applicant;
14. (o) Evidence of paid-in working capital or binding credit agreement which equals six months operating expenses in the aggregate;
15. (p) Analysis of the improvement in cost effectiveness to the provider as a direct result of the proposed service;
16. (q) Analysis of how the proposed service would integrate with the current emergency medical service system;
17. (r) Proof of insurance or letter of intent for new services at levels required of by section 19a-180-2(d) of these regulations; and
18. (s) Any other information as may be included by the applicant;

(Effective December 15, 1983)