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City of La Porte <br />Established 1892 <br />INVOICE <br />AMBULANCE SERVICE FEE <br />October 1, 2017 September 30, 2018 <br /> <br />The EMS service fee is $29.37 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 /> <br />Date: ____________________________________________ <br /> <br />Company Name: ____________________________________ <br /> <br />Site Address: _______________________________________ <br /> <br />Contact Email: ______________________________________ <br /> <br />Number of Employees _______________ <br /> <br />Recurring Contract Workers _______________ <br /> <br />Total Covered Personnel _______________ <br /> <br />X $29.37 <br /> <br />Total Fees Due _______________ <br /> <br />I certify that the above employee and contract worker count is accurate to the best of my <br />knowledge. <br /> <br />________________________________________________ <br />Site Manager (Signature) <br /> <br />________________________________________________ <br />Site Manager (Print Name) <br /> <br />****** PLEASE RETURN THIS FORM ****** <br /> <br />THIS FORM MUST BE SIGNED BY THE SITE MANAGER AND RETURNED ALONG <br />WITH A CHECK NO LATER THAN FEBRUARY 1, 2018. <br /> <br />Make check payable and mail to: City of La Porte - EMS <br />P.O. Box 1359 <br />La Porte, Texas 77572-1359 <br /> <br />