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a <br /> 5 <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: <br /> I . APPLICANT: <br /> A. Name of Applicant: C,4Gd 17e.prt' <br /> B. Address :Street: 700 G-v�ss hc\ <br /> City/State: Ryo,;,e- i'nv y t- A/ C_ Zip 27-1-7 Z <br /> C. Telephone No. at Base of Operations: -73-a- 3 ­4 <br /> D. Name of Owner/Contact Person: <br /> E. Address:Street: 5-1 OF LJA(_kers' F-4rm Rcc <br /> City/State: H`r LCS�a r�� �1, )1/ Zip ,-2 7,�-? <br /> F. Telephone No. :- 7-7 a- u 03 It <br /> G. *Trade Name: 0AJ_S u:,-.U H. Category of Franchise Applied For (A separate <br /> application must be completed for each category of <br /> service applied for) : <br /> BLS: ALS: RES;B SERVICES <br /> [ ] First Responder [ J D-Level ( PI xtrication <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 /> v2! 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 /> A financial statement as it pertains to operations <br /> in Orange County. <br /> A A copy of Organization's By=Laws (if applicable) . <br /> �! A copy of Organization's Standard Operating <br /> Procedures . <br /> A current roster of members to include name, <br /> address, and social security number. <br />