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s 7 <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: <br /> 1,/ A.r <br /> I . APPLICANT: <br /> A. Name of Applicant: )iv0 �"��rZ /-' 144-yh.LI Snr�rc�� <br /> B. Address :Street:- C( U•.S. y <br /> zip <br /> City/State: �/ ._fj /�r� ,C-. <br /> C. Telephone No. at Base of operazi.ors = .3 �-3 �y G 7 <br /> D. Name of Owner/Contact Person: Gh rri <br /> E. Address:Street: 3`f 0 <br /> City/State: !.'L/ ni►1 /V• (L zip :Z 7 '705 <br /> F. Telephone No. :—rr L7/ y '3 F..3 - ' "d <br /> G. *Trade Name: r,,,rg AsA7,1- <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 /> [ ] 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 /> H. ATTACHMENTS REQUIRED: <br /> 1. Certified copy of Articles of Incorporation Charter <br /> or *Assumed Name Certificate. <br /> QResume' 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 /> S . 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 />