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i <br /> 9 <br /> a <br /> APPLICATION <br /> FOR <br /> AMBULANCE RESCUE OR MEDICAL FIRST RESPONDER FRANCHISE <br /> ORANGE COUNTY, NORTH CAROLINA <br /> Date of Application: March 1, 1994 <br /> I. APPLICANT: <br /> A. Name of Applicant: Orange Grove Fire Department <br /> B. Address:Street: 6800 Orange Grove Road <br /> City/State: Hillsborough, N. C. Zip 27278 <br /> C. Telephone No. at Base of Operations: 919-967-5858` <br /> D. Name of Owner/Contact Person: Tommy Holmes <br /> E. Address:Street: 4311 Bradshaw Quarry Road <br /> City/State: Efland N. C. Zip 27243 <br /> F. Telephone No. : 919-563-6505 <br /> G. *Trade Name: N A <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 REOUIRED: <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 />