2152 Astoria Circle # 104
Herndon, VA 20170
Fax 703 657-0340

e-APIS INFORMATION - AFTER SELECTING DEPARTURE OR ARRIVAL NOTIFICATION AS APPROPRIATE, ALL FIELDS ON THIS FORM ARE MANDATORY FOR U.S. CUSTOMS CLEARANCE - ANY FIELDS LEFT BLANK CONSTITUTES DENIAL OF THE CLEARANCE

Customer Name
Contact Name
Contact's e-mail
Contact's Business Phone Number
Contact's Cell Phone Number
Contact's Fax Number
Billing Address
Delivery Address
Relationship to Patient

PATIENT DETAILS

Patient Name
Medical Condition of Patient:
MEDICAL CREW AND GROUND AMBULANCE DETAILS
Medical Crew to be Provided byClientUs
Ground Ambulance to be Provided byClientUs  if us:  ALSBLS

If we Provide the Ground Ambulance

Pick-up OnlyDrop-off OnlyBoth
TRANSFER INFORMATION
Date of Transfer
FROM: Name of Hospital/Other
City
State
Country
TO: Name of Hospital/Other
City
State
Country
Number of Passengers Accompanying Patient
Comments:
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