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<br />CERTIFICATION AND ACCEPTANCE <br />The Applicant hereby certifies that: <br />1. It has read and understands the terms and conditions of the Office of Emergency Medical <br />Services October 16, 2003, Request for Proposal; <br />2. It agrees to those terms and conditions without exception; <br />3. It shall use the grant funds solely for the purposes specified in the attached application; <br />4. It has included all project costs in the attached budget; and <br />5. It has authorized the execution of this certification page by the officers whose signatures <br />appear below. <br />APPLICANT: Orange County Emergency Medical Services <br />ADDRESS.: P.O. Box 8181 <br />CITY: Hillsborough STATE NC ZIP: 27278-8181 <br />TELEPHONE NUMBER: (919) 968-2050 <br />FEDERAL EMPLOYER ID: 56-6000327 <br />By: <br />Signature, County Manager Date <br />John Link <br />Printed Name <br />ATTEST (CORPORATE SEAL) <br />By: <br />Signature Date <br />..~ <br />Printed Name Title <br />THE APPLICANT'S PROPOSAL IS HEREBY ACCEPTED BY GEMS <br />DIVISION OF FACILITY SERVICES (DFS) ASSIGNED NUMBER: <br />DFS ASSIGNED PURCHASE ORDER NUMBER: <br />By: <br />Drexdal Pratt, Chief, Office of Emergency Medical Services <br />By: <br />Robert J. Fitzgerald, Director, Division of Facility Services <br />The Applicant must sign this page and include it in its application <br />Unsigned proposals shall not be considered <br />Two original signature copies of this form shall be submitted <br />Date <br />Date <br />5 <br />