DOH-1881 Affirmation of Compliance Submission Portal

Check One
Personal Information
Contact Information
List All Vehicles For Agency Recertification or Only The New Vehicle(s) To Be Added
If Vehicle(s) is New to Fleet, Please Indicate If You Need Certification Logos For The Sides and Rear of The Vehicle
License Plate # Radio or Agency ID Motor Vehicle ID # (VIN) Make Year Color Vehicle Type
More Vehicles

All certified ambulance services must: "Display on the exterior of both sides and the back of all ambulances and emergency ambulance service vehicles the name of the service in letters not less than 3 inches in height and clearly legible. The logo provided by the department shall also be displayed on both sides and the back of every ambulance and shall be removed upon sale or transfer of the vehicle."[10 NYCRR Part 800.21(e)]

 

Front (Must Include Inspection Sticker) Rear (Must Include License Plate) Side View
Upload requirements
Upload requirements
Upload requirements
More Vehicles
Upload requirements
Do you need to remove any vehicles?
Removal of Vehicle
License Plate # Radio or Agency ID Motor Vehicle ID # (VIN) Make Year Color Vehicle Type
More Vehicles
Affirmation and Acknowledgement

By completing and signing this affirmation, I certify that the vehicles listed are in compliance with all requirements of the State EMS Code, Part 800.

The records and documentation of the agency have also been reviewed for compliance with all applicable requirements.

The ambulance vehicles listed are registered with the NYS Department of Motor vehicle (DMV) and the appropriate DMV inspection has been conducted. Those vehicles which are not ambulances have appropriate DMV registration, DMV inspection, and/or any safety inspection as required by the NYS Department of Transportation, The United States Coast Guard, or the Federal Aviation Administration.

I understand that under the authority of the Public Health law any deficiencies that result in violations being issued are subject to the penalties of the Public Health Law, including fines, suspension, revocation or annulment of the operating certificate.