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Orange County Emergency Management <br />P. O. Box 8181, Hillsborough, NC 27278 <br />Office (9 19) 968 -2050 Fax (919) 968 -4066 <br />APPLICATION FOR FRANCHISE <br />AMBULANCE * EMS * MEDICAL RESPONDER * RESCUE <br />Name of Applicant: _6 <br />Primary Local Business Address: 4q <br />Local Address City / State / Zip: <br />C <br />Date of Application: 05/ ca 02 <br />Telephone number at local base of operations: L41 3014-6103% I �r,✓�.o <br />Name of Owner / Contact Person: <br />Main Office / Owner / Contact Per. <br />Main Office City / State / Zip: <br />Telephone number at main of <br />Operating Business / Trade N <br />Please Mark Category of Franchise Applying For: <br />(A separate application must be completed for each general category of service) <br />Ambulance Ememency Medical Medical Responder Rescue <br />[41 BLS non - emergency [ ] BLS transport [ j First Responder [ ] Extrication <br />[ ] ALS non - emergency [ ] ALS non - transport [ J EMT Responder [ ] High / Low Angle <br />[ ] ALS transport [ ] Confined Space <br />[ ] Trench, Collapse <br />[ J Swiftwater <br />[ J Underwater <br />- - Application Attachments Required <br />(See Orange County Franchise Ordinance for Additional Details) <br />1. Certified copy of Articles of Incorporation and / or Charter <br />2. Applicant's resume of training and experience category of service applying for franchise <br />3. Financial statement pertaining to [proposed] operations in Orange County <br />4. Copy of organization by -laws (if applicable) <br />5. Copy of organization standard operating procedures <br />6. Current roster of all members and employees, including name, address, and NCDL number. <br />7. Proposed fee schedule for service in Orange County <br />