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JUN 26 '95 08:14 4 • <br /> �► 7 <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER *FRANCHISE <br /> ORANGE COMM, NORTH CAROLINA <br /> SiOisssCaisssa6asss�aRSAt�tsaaasicssaasi7sWCas.:sax ax+t Siaszass7CSasassassaS7isa3iiis <br /> Date of Application: 6/21/95 <br /> I. APPLICANT: <br /> A. Name Of Applicant: White Cross Fire Department <br /> S. Address:Street: 5722 old Greensboro Hwy <br /> City/State: Chapel Hill, N.C. Zip 27516 <br /> C. Telephone No. at Base of Operations: (919) 942-1194 <br /> D. Name of Owner/Contact Person: Robert Smith <br /> E. Addrers:Street: 5722 old Greensboro Hwy <br /> City/State: Chapel Hill, N.C. Zip 27516 <br /> F. Telephone No. : 967-5578 <br /> G. *Trade Names White Cross Fire Department <br /> A. Category of Franchise Applied ror (A separate <br /> application must be completed for each category of <br /> service applied for) : <br /> BLS: ALS: RESCUE SERVICES <br /> [ ] First Responder [ J D-Level Fx] Extrication <br /> [ ] Emergency Med Techn. ( ] I-Level [ J High/Low Angle <br /> [ ] Convalescent Transport ( ] P-Level [ ] Confined Space <br /> [ J Trench <br /> ] <br /> A. ATTACHMENTS REQUIRED: [ Water <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 />