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APPLICATION _ <br /> FOR --- -— �, <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCH2SE----------------------- <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: Z -/4- ql <br /> I. APPLICANT: <br /> A. Name of Applicant: A1,1, k � a+kam 4b1• Frc ideogo,fivNef f <br /> B. Address :Street: LL n1Grr') S Dark <br /> City/State: P J HSboro.. A'• C Zip „Z ?-31 2- <br /> C. Telephone No . at Base of Operations: --3.3(YL% <br /> D. Name of Owner/Contact Person: Irat-k- 1 n#Qasbet <br /> E. Address:Street: SC'"rne AS Pbove " <br /> City/State: Zip <br /> F. Telephone No. : 13 <br /> G. *Trade Name: <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: RESCUE SERVICES <br /> [ J First Responder [ ] D-Level C>ej Extrication <br /> [ ] Emergency Med Techn. [ ] I-Level [ ] High/Low Angle <br /> [ ] Convalescent Transport [ ] P-Level [ ] Confined Space <br /> [ ] Trench <br /> [ ] Water <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 />