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a � <br /> FE9 2 "'^? <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> APPLICANT: <br /> Date of Application: <br /> I . <br /> A. Name of Applicant: DfLX} �6f= ('�✓F J� 1 il?r-5 UEP1, <br /> B. Address :Street: lyfUy ��fP/a �✓Ec �Poyr 2-1, <br /> City/State: rk�S "d v X 41 e, zip ,� �2 W <br /> C. Telephone No, at Base of Operations: <br /> _ ll <br /> D. Name of Owner/Contact Person: l d 17'4 f <br /> E. Address :Street:— 31/ ell o l <br /> City/State: /� �� /����, zip-2 7�2 7� <br /> F. Telephone No. /���/�'� f/y - S C3'�s=0G &Vla A Y/f- 17 <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: RES SERVICES <br /> [ J First Responder [ J D-Level [Extrication <br /> [ ] Emergency Med Techn. [ ] I-Level [ ] High/Low Angle <br /> [ ] Convalescent Transport [ J 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 />