Letter of Good Standing Request Form

Date

Name *

Address *

System ID#

What agencies do you currently work for within the Morris Hospital EMS System region? *

Cell Phone# *

Email *

What EMS System does the Letter of Good Standing need to be sent to? *

Who is the EMS Coordinator for that System? *

What is the fax number or email to send the letter to? *

What EMS System will be your Primary System? (MHEMSS or ?) *

Please check the box that is appropriate: (You may not stay in the Morris EMS System unless you remain employed with an agency in the system) *

I plan to stay in the Morris Hospital system

I am dropping Morris Hospital EMS System since I no longer work for one of its agencies

If you plan to stay in the Morris Hospital EMS System, what agency will you be with?