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c F <br /> 3 <br /> !APPLICATION <br /> FOR <br /> AL <br /> AM8ULl4NCB RESCUE OR MSDZCAL FIRST RSSPCf1IDBR FRANCHISE <br /> ORANGE COUNTY, MORTH CAROLINA <br /> �.�a s�Sxmmi=iiiSiiarig RTS�RSS.T.'aeaY Y.i'di iC imiai msiil�i0i AmsSa axe aeOyC i'�!S <br /> APPLICANT: Date of Applications March 14, 1994 <br /> Y. <br /> A. Name of Applicants JOHNSTON AMBULANCE SERVICE , INC . <br /> E. Address:Streets 1008 S. Pollock , PO Box 283 <br /> City/State: Selma , North Carolina gip 27576 <br /> C. Telephone No. at Base of Operations: 919-965-2249 <br /> D. Name of Owner/Contact Person: Leon Cannady, Sr. , President <br /> R. Address:Streets game as above <br /> city/State: same as above gip <br /> F. Telephone No. : 919-965-2249, 919-839-1125, 800-635-3500 <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 [ j D-Level [ ] Extrication <br /> [ ] Emergency lied Techn. [ ] I-Level [ ] High/Low Angle <br /> �] Convalescent Transport { j P-Level [ j Confined Space <br /> [ ] Trench <br /> [ ] Water <br /> H. REQUIRED: <br /> 1. Certified copy of Articles of Incorporation Charter <br /> or *Assumed Certificate. <br /> 2. Resume' of training and experience of the applicant <br /> in rescue and transportation and care of patients. <br /> 3. A financial statemaent as it pertains to operations <br /> in Orange County. <br /> 4. A copy of Organization's Sy-Laois (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 />