Thank you very much for sending your service request, a flight coordinator will contact you soon.


Ambulance Service Request
TODAY'S DATE

   
Requested by
 Company
 Billing address
E-mail
 Phone
 Fax
FLIGHT INFORMATION
Aircraft Type
 Tail Number
 Trip Number
 
Are you part 135 Indefinite Blanket Permit holder?

If not, you must apply to get a one time permit.
 

PLEASE MARK THE SERVICES YOU WILL REQUIRE

GROUND HANDLING FULL SERVICE PACKAGE

FULL SERVICE INCLUDES:

Representation, Landing, Parking and Aircraft Immigration fees, Ramp service, Flight Plan Coordination, Customs Immigration and Health Clearances, Flight Following, Gratuities, Crew Transportation (fare up to $50 USD), Fuel Coordination, FBO Facilities, Communications, 15% Airport Royalty, and Pax / Crew Assistance.

Complimentary Services:

Basic Catering, Weather Information, Hotel and Car rental reservations, Into Plane Supervision.

Inbound Patient(s) #
Inbound Passengers(s) #
Outbound Patient(s) #
Outbound Passengers(s) #

Additional Services to the Full Service Package

One time permit
Car rental
Fuel with ICCS
Type
Other
# Days
Overnight
Hotel reservation
Overtime
# days
Aircraft security
# rooms
Pax Ground Transportation

Ground Ambulance
   
 
Hospital
Local Contact Name
Address
Phone
ITINERARY
 
ICAO ID/Airports
Date (Z)
ETA(Z)
ETD(Z)
Number of PAX
From:
To:
From:
To:
From:
To:
From:
To:
Flight Crew
Name
DOB
License #
Citizenship
Captain
First Officer
Other
Doctor
Nurse
Paramedic
         
Patient
Name
DOB
Passport#
Citizenship
1
2
         
Pax
Name
DOB
Passport#
Citizenship
1
2
3
4
5
Specific Needs


Catering


PAYMENT GUARANTEE
Credit Card Type
 Number
 Expiration Date
 Security Number
Your credit card only guarantees the defrayment of the services after the thirty-day credit period