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This completed form MUST be submitted with your application for Life Support Vehicle License BHS-EMS-0181.
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A LICENSE WILL BE REVOKED. The form will be returned by the final manufacturer. If the form is not received within 30 days of application, the application will be denied and the fee will NOT be refunded. NOTICE WILL BE RENDERED TO THE APPLICANT A FEE OF SIX HUNDRED SIX FIVE DOLLARS (USD) RESULTING FROM THE APPLICATION OF THIS LICENSE; AND FROM THE PRICE OWED BY THE DEPARTMENT OF HEALTH FOR THE LICENSE AND SIX DOLLARS WILL BE CHARGED TO THE APPLICANT. The fee is due and payable at the time of application. For further information about this program contact: H.M. Department of Safety & Community Services, Michigan Department Of Community Health, 401 East Grand River Drive, Lansing, MI 48 or e-mail: HDS_EMS_Programmichigan.gov.

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