Renewal Form Oregon Volunteer Ems Provider Tax Credit Certification - 2013-2014
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1RENEWAL FORM
Oregon Volunteer EMS Provider 2013-2014 Tax Credit Certification
This form is electronic. If possible, please fill out as much on the computer as one can before printing and signing.
EMS Provider
Station/Agency
Name: ___________________________________
(Complete only if applicable. Please print legibly.)
(First, M.I., Last - please print legibly.)
New Primary Station/Agency
Signature: _________________________________
Name: ______________________________________
E-mail: ___________________________________
Street: ______________________________________
(Please print legibly–this is how we send confirmations.)
City: _______________________________________
Last four numbers of S.S.: ________________
State: OR
Zip: ___________
Daytime Phone: (_____) _____ - __________
Phone: (_____) _____ - _____________
New mailing address as of 2014:
_________________________________________
EMS Provider Supervisor Printed Name:
Street Address
_________________________________________
___________________________________________
City
State
ZIP
EMS Provider Supervisor Signature:
Status
£ My Primary Station/Agency location (city) has not
___________________________________________
changed during 2014.
New Secondary Station/Agency
£ My Total Volunteer Hours have changed:
Paid Hours: _______ Volunteer Hours: ________
Name: ______________________________________
Street: ______________________________________
£ I retired as a volunteer EMS Provider on:
_________,2014.
City: _______________________________________
(Mo./Day)
£ I moved to a different state on _________,
State: OR
Zip: ___________
(Mo./Day)
Phone: (_____) _____ - _____________
2014 and no longer volunteer as an EMS Provider in
Oregon.
New Tertiary Station/Agency
£ I moved back to Oregon from a different state
on _________, 2014 and now volunteer. ß
Name: ______________________________________
(Mo./Day)
Street: ______________________________________
£ As of ________, 2014, I now volunteer in a
City: _______________________________________
(Mo./Day)
different city in Oregon. ß
State: OR
Zip: ___________
Phone: (_____) _____ - _____________
ß New Station/Agency information on the right is
required for these fields only.
Either fax completed form to (503) 494-4798 or mail to:
Oregon Office of Rural Health | 3181 SW Sam Jackson Park Rd., L-593 | Portland, OR 97239
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