LOS ANGELES COUNTY - DEPARTMENT OF HEALTH SERVICES
C
ounty
W
ide
I
ntegrated
R
adio
S
ystem
Radio Distribution Inventory
All fields are required
Date :
mm/dd/yyyy
LID :
Radio Type :
Serial # :
(i.e. MRK,MPA, P7100)
Name :
Dept :
Office Address :
Employee # :
City :
Room # :
Zip :
Telephone # :
(###) ###-####
EMail :
Fax # :
(###) ###-####
By submitting this electronic form I am assuming responsibility for the listed radio
Please Print a copy of this form for your records before submitting
______________________________________________________________
For EMS Use Only
Status :
Date Registered :
LID Reference # :