Regional ALS Agency Application
STEP 1: Complete the electronic form below.
STEP 2: Submit the following accompanying documents via email to firstname.lastname@example.org. If necessary, you may also fax to (518) 793-5833 or mail to Mountain Lakes Regional EMS Council, 375 Bay Road, STE 202, Queensbury, NY 12804.
- NYS DOH BEMSTS Operating Certificate
- NYS DOH Controlled Substance License
- Agency roster (must indicate name, level, position in agency, volunteer/paid and NYS certification #)
- Copy of agency coverage schedules (current, and past 3 months)
- Insurance certificate which shows a minimum of one million dollars medical malpractice insurance, one million dollars general liability and appropriate vehicle coverage
- Signed Mountain Lakes Internship Agreement (sent to you via email)
- Signed and Notarized Signature Page (sent to you via email)
- Any documents that support answers to the questions below
Agency ALS Application
Upon completion of the following fields and hitting the send button, your online application will be emailed directly to the Mountain Lakes office.