Notification of Changes for Business Entity
General Information
Business Entity Name:	TRAVEL MEDEVAC LLC
Incorporation / Formation Date:
FEIN:	474052875
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	AZ
County:	COCONINO
Business Address
Address 1:	214 E BIRCH AVENUE
Address 2:
City:	FLAGSTAFF
State:	AZ
Zip:	86001
Phone:	6023449225
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	214 E BIRCH AVENUE
Address 2:
City:	FLAGSTAFF
State:	AZ
Zip:	86001
Indicate the type of change you are seeking
Address Change:	YES
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
DELMIRA BUTLER

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	DELMIRA BUTLER
Title:	COMPLIANCE SPECIALIST
Phone Number:	2547296129
Email Address:	DBUTLER@ILSAINC.COM