Orange County NC Website
Browse       Search
APPLICATION <br />FOR <br />AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br />I. APPLICANT: <br />ORANGE COUNTY, NORTH CAROLINA <br />Date of Application: A...», s =, oj-- <br />A. Name of Applicant: <br />B. Address: Street: Ro. Bvx b1384 <br />City /State: D,,,H.►r, iyc Zip z -4-415 <br />C . Telephone No. at Base of Operations: "1+1 - ;47- - IsI C <br />D. Name-of Owner /Contact Person: <br />E. Address : Street: 3211 - y Vn-yus ►h 5�1+111 QA . <br />City/State:_ Zip ZjjaS <br />F. Telephone No.: q +9 �gz. 1396 <br />G. *Trade Name: CIA <br />H. Category of Franchise Applied For (A separate <br />application must be completed for each category of <br />service applied for): <br />BLS: <br />ALS: <br />RESCUE SERVICES <br />[ j First Responder <br />[ ] D -Level <br />[ ] <br />Extrication <br />[ j Emergency Med Techn. <br />[ ] I -Level <br />[ ] <br />High /Low Angle <br />[ ] Convalescent Transport <br />[ ] P -Level <br />[ ] <br />Confined Space <br />[ ] <br />Trench <br />[X] <br />Water/ 0- J-,••;'v <br />H. ATTACHMENTS REQUIRED: <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 />6. A current roster of members to include name, <br />address, and social security number. <br />�Q' �ScJBh bail <br />