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3 <br />APPLICATION <br />FOR <br />AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br />ORANGE COUNTY, NORTH CAROLINA <br />I. APPLICANT: <br />Date of Application: ~..M~r zz , ~»~ <br />A. Name of Applicant:Dr-..~< c-~ IN,terw.+~ Se.~.«~ A,.~ ~<o~~~'(e..,•,.,~~ <br />B. Address:Street: Ro. Box 61384 <br />City/State: D~rt+•-.,. iyc Zip z~~~5 <br />C. Telephone No. at Base of Operations: 1W - >4t~939~ <br />D. Name'of Owner/Contact Person: ~.ew~s I,b,,.w.~k (c+~c.f) <br />E . Address :Street: 3zti - y V"~vus-}~ 5~,+~b`^ ~•l - <br />City/State: bvtl~a.rr Zip Z~~aS _ <br />F . Telephone No .: q~9 • ~Ei- 139b <br />G . *Trade Name : 111 <br />H. Category of Franchise Applied For (A separate <br />application must be completed for each category of <br />service applied for): ._ <br />BLS; ALS: RESCIIE SERVICES <br />[ ] First Responder [ ] D-Level [ ] Extrication <br />[ ] Emergency Med Techn. [ ] I-Level [ ] High/Low Angle <br />[ ] Convalescent Transport [ ] P-Level [ ] Confined Space <br /> [ ] Trench <br /> [X] Water/ Un.<<:,,•.~2r <br />H. ATTACHMENTS REQIIIRED: <br />1. Certified copy of Articles of Incorporation Charter <br />or *Assumed Name Certificate . <br />2. Resume' of training and experience of the applicant <br />in rescue and transportation and care of patients. <br />3. A financial statement as it pertains to operations <br />in Orange County. <br />4. A copy of Organization's By-Laws (if applicable. <br />5. A copy of Organization's Standard Operating <br />Procedures. <br />5. A current roster of members to include name, <br />address, and social security number. <br />spa [s~,,en ~~;,. <br />