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3 <br /> i <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: May 24, 1995 <br /> I . APPLICANT: <br /> A. Name of Applicant: New Hope Fire Department and Emergency <br /> B. Address.•Street.• 4700 NC 86 South Medical Services Inc. <br /> City/State: Chapel Hill , NC Zip 27514 <br /> C. Telephone No. at Base of Operations: (919) 929-3473 <br /> D. Name of Owner/Contact Person: Walter Mills, Chief <br /> E. Address:Street: 4700 NC 86 South <br /> City/State: Chapel Hill , NC Zip 27514 <br /> F. Telephone No. : (919) 929-3473 Pager- 216-0802 <br /> G. *Trade Name: New Hope Fire Department and Emergency Medical <br /> H. Category of Franchise Applied For (A separate Services Inc. <br /> application must be completed for each category of <br /> service applied for) : <br /> BLS: ALS: RESCUE SERVICES <br /> [ First Responder [ ] D-Level [X)] 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 />