Licensed Agency Custom Report Request Form

The Reports listed below may obtained from the Licensing and Certification Section by completing the information listed below. An e-mail of your request will be sent to the Licensing and Certification Section. The Reports requested will be e-mailed to the e-mail address provided.

Please register and indicate the document(s) you would like to receive.

Name: Business/EMS Agency Name: Agency License Number

Address: City State: Postal Code:

Phone: E-Mail Address:

Reports Requested:

Agency Information Sheet:

Personnel Listing:

Vehicle Listing:

After selecting the document(s), click on the "Register" Button ONCE ONLY

If you have questions or comments, or clicking on the "Register" Button results in an Error, contact the Licensing and Certification Section.

= Required information

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Office of Emergency Medical Services and Trauma System
P.O. Box 47853,
Olympia, Washington, 98504-7853
Phone: (360) 236-2828
(Fax: 360) 236-2830

Last Update : 04/30/2009 11:15 AM
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