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ATTACHMENT 1 <br /> 4 ` <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: Auqust 12, 1996 <br /> I. APPLICANT: <br /> A. Name of Applicant: Mid-South Medical Transport, L.L.C. <br /> B. Address:street: 804 Brightleaf Boulevard, Post Office Box 1162 <br /> City/State: Smithfield, North Carolina zip 27577 <br /> C. Telephone No. at Base of Operations: (919) 934-4206 <br /> D. Name of Owner / Contact Person: Terry W. Heuser <br /> E. Address:street: 886-D Short Journey Road <br /> City/State: Smithfield, North Carolina zip 27577 <br /> F. Telephone No. : (919) 934-4206 <br /> G. *Trade Name: Mid-South Medical Transport, L.L.C. <br /> H. Category of Franchise Applied For (A seperate <br /> application must be completed for each category of <br /> service applied for) : <br /> BLS: ALS: RESCUE 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 /> [ ] Water <br /> I. ATTACHMENTS REQUIRED: <br /> 1. Certified copy of Article 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 /> f . <br />