Affirmation of Compliance

Forms Used in EMS Agency Application

General Instructions for Form Completion

This form is used to identify and document all certified vehicles operated by an authorized certified EMS agency. All EMS vehicles possessing red lights and siren that are used by a service and classified within NYS Dept of Motor Vehicles definition as "Authorized Emergency Vehicles" (AEV) must be listed on this form. Additionally, each listed vehicle must be compliant with required equipment per Article 30 of Public Health Law and NYCRR Part 800 whenever operated as an AEV. The Department reserves the right to inspect any affirmed vehicle at any time or location with or without advance notice. Services are required to report the garaging / storage locations of all AEVs on Department form DOH-206 in section 23.

DOH-1881 Item Information required to complete
Page 1 Check Boxes Check type of service: Ambulance Or ALS First Response
Current Expiration If this application is for renewal or update, fill in the expiration date of the agency's current, or to be renewed, operating certificate
Service Info Provide Name of Service, DOH Agency ID number, Address, City, State, Zipcode, Name and Title f Chief Operating Officer and Daytime phone number at which this person can be reached.
READ AFFIRMATION This is a legal statement to which teh signing individual is affirming compliance with all laws and regulations applicable to the operation of the vehicles listed on the reverse side. Willful misrepresentation and/or deficiencies in equipment or mandatory compliance may subject the signee and/or the EMS service to fines, suspension, revocation or annulment of the operating certificate.
PRINT Name and title of person signing the affirmation
SIGN Sign the form with notary affirmation and acknowledgement. Leave the gray shaded box in the lower right hand corner blank.
Page 2 Check Boxes If any of the vehicles are NEW or are missing DOH Certification logos (must be on 3 sides of vehicle), check YES box and indicate the number of logo emblems needed. If your vehicles already have the required emblems, check the NO box.
Vehicle Information For each vehicle, list the DMV license plate assigned, the unit or radio identifier that uniquely identifies that vehicle, the Motor Vehicle Identification # (VIN), the manufacturer's make, the year of manufacture, the principal color, and vehicle type per the list at the bottom of the page. NOTE: A "Fly Car" is NOT a vehicle type. Non transport vehicles operated by ambulance services are EASVs. Non transport vehicles operated by ALS First Response Agencies are ALSFR type vehicles.

NOTE: The total number of vehicles identified by type must match the number of vehicles reported on Department form DOH-206 in section 24.