Agenda - 04-06-2010 - 7b - Laserfiche WebLink

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6 Q%.,Pqt'fro&t ORANGE COUNTY EMERGENCY SERVICES APPLICATION FOR SERVICE FRANCHISE a Franchise Application Category (A separate application must be completed for each general category of service.) Convalescent Transport Services Rescue Services ❑ALS Transport ❑Confined Space (For OCES use only) Q BLS Transport ❑ Extrication Emergency Services ❑ Heavy Rescue OALS Transport ❑ High/Low Angle Date Received: BLS Transport ❑Swift Water OMedical Res po nder Non trans ort Trench Collapse : ❑ EMT Non-transport ❑ Underwater Wilderness Search& Rescue I Name of Applying Organization: Johnston Ambulance Service,.Inc_ Primary Local Business Address: 4018 Hillsborough Road Ali: Durham,NC 27703 � Local Address City/State/Zip: Telephone number at local base of operations; 919-384-9100 Name of Owner/Contact Person: Jeffrey D.White,Vice--President Main Office/Owner/Contact Person Address: 2803 Highway 70 blest Main Office City/StatetZip: Goldsboro,NC 27530 Telephone number at main office: 800-525-3500 - Operating BusinessfTrade Name: WIN- i .. Application Attachments Required z (See orange county Franchise ordinance for additional Details) - 1.Certifed copy of an assumed name certificate if applicant does business under a trade name AND trade -_ name does.not appear on the Articles of Incorporation or Charter. :i 2. Certified copy of Articles of Incorporation and/or Charter. 14 Section III r : 3. Applicant's resume' of training and experience for the applicable service. SeWon IV 4. A full description of the type and level of service to be provided including the location of the place or ' places from which it is intended to operate,the manner in which the public will be able to obtain assistance t and how the vehicle will be dispatched. Sermon V 5. Financial statement pertaining to(proposed)operations in Orange County. Section VI �i•- F�--i'