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OHlce of Orange County Emergenty Management <br />PO Bax 81 8 1, Hillsborough, NC 2 ]2 ]8 <br />Of/ICe (919) %8-2050 Fax (919) 966-4066 <br />APPLICATION FOR FRANCHISE <br />AMBULANCE • MEDICAL FIRST RESPONDER' RESCUE <br />Oate o/ Application: <br />Name of Applicant CAROLINA AIR CARE <br />CitylSlate: CHAPEL HILL NC Zip: 2]514 <br />Telephone # At Base of Operations: !9191 %6 3044 <br />Name of Owner/COntraU Person: _ UNC HOSPITALS <br />Atltlress: (Street) 101 MANNING DRIVE <br />Ciry/State'. CHAPEL HILL Zip. 2]514 <br />Telapho~eit: 191919663041-L 10f( <br />CATEGORY OF FRANCHISE APPLIED FOR: <br />(A separate application must be completed for each category of service applied for) <br />BLS ALS RESCUE SERVICES <br />(]First Respontler (] D-Level [ ] Extrication <br />[ ]Emergency Metliwl Technician [ ] I-level [ ] HigNLOw Angle <br />[ ] onvalescaM (NOn-Emergency) ~'P-Level [ 7 Confnetl Space <br />[ Transport [ ]Trench <br /> [ ] Water <br />IX] Specialized Transport-Piedmont WomenS Health Center <br />ATTACHMENTS REpUIRED: <br />1. CeNfe0 copy of ANUes of Inwmoregon Charter or •Aaeumetl Neme Ceniflcate <br />2. Applicants Resume' of Veining/experience in reawe, tranaportatlon, antl pegent care <br />3. Finanual Btalement pertaining ro operagons in Orange County <br />4. Copy of Organizagon's By-Laws (6 applicable) <br />5. Copy of Orgenizafon's Standard Operating Prdwdures <br />fi. Cunant RosNr of Members inclutling names, addresses, and soaal zewdty numbers <br />