Non-Medical Mobile Service Provider Permit Application

Has a Non-Medical Mobile Service Provider Permit been issued for this vehicle in the past?*

No - This will be the first permit associated with this vehicle.Yes - A permit has been issued for this vehicle in the past.
Previous Permit Number*

Organization Information
Organization Name*
Organization Phone Number*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information

The contacts listed below shall be the natural person(s) who will be responsible for supervision of the provision of non-medical mobile services with the 7th councilmanic district.
Primary Contact Name*

First NameLast Name
Primary Contact Phone Number*
Please enter a valid phone number.
Primary Contact Email*
example@example.com
Primary Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Contact Name

First NameLast Name
Alternate Contact Phone Number
Please enter a valid phone number.
Alternate Contact Email
example@example.com
Alternate Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Vehicle Information
License Plate of Vehicle Providing Non-Medical Mobile Services*
Vehicle Make*
Vehicle Model*
Vehicle Year*
Vehicle Color*
Upload a copy of the vehicle registration*

Cancelof
Description of Services
Describe the non-medical services to be provided. *
Schedule
Will you provide non-medical services on a regular schedule?*

YesNo
Describe your anticipated schedule. Provide as much detail as possible. *

L&I Approver - Complete the Two Fields Below