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L 16 City of La Porte <br />0 Established 1892 <br />INVOICE <br />AMBULANCE SERVICE FEE <br />October 1, 2011 — September 30, 2012 <br />The ambulance service fee is $26.86 per on -site employee and shall include the number of <br />recurring contract workers. Please list the number of covered personnel at your site, figure in <br />the total fee due and forward this form along with your fees to the address listed below. <br />Date: <br />Company Name: <br />Number of Employees <br />Recurring Contract Workers <br />Total Covered Personnel <br />Total Fees Due <br />X $26.86 <br />I certify that the above employee and contract worker count is accurate to the best of my <br />knowledge. <br />Signature of Site Manager <br />* * * * ** PLEASE RETURN THIS FORM * * * * ** <br />THIS FORM MUST BE SIGNED BY THE SITE MANAGER AND RETURNED ALONG <br />WITH A CHECK NO LATER THAN JANUARY 1, 2012. <br />Make check payable and mail to: City of La Porte - EMS <br />P.O. Box 1359 <br />LaPorte, Texas 77572 -1359 <br />