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1 IT -ri.Ti ORANGE COUNTY EMERGENCY SERVICES <' �,. 0 <br /> vkx PJ <br /> fit. <br /> �� APPLICATION FOR SERVICE FRANCHISE , <br /> o��b �6tb‘‘s E RGERGy <br /> 8ERVICEC+ <br /> Franchise Application Category <br /> (A separate pplication must be completed for each general category of service.) <br /> Convalescent Transport Services Rescue Services <br /> ❑ ALS Transport ❑ Confined Space <br /> ❑ BLS Transport ❑ Extrication (For OCES use only) <br /> Emergency Services ❑ Heavy Rescue <br /> ❑ BLS Supplemental Transport ❑ High/Low Angle Date Received: <br /> ❑ BLS System Surge Tansport 0 Swift Water <br /> ❑ BLS Special Event Transport ❑ Trench Collapse <br /> ❑ Medical Responder Non-transport ❑ Underwater <br /> ❑ EMT Non-transport ❑ Wilderness Search & Rescue <br /> Name of Applying Organization: First Choice Medical Transport, LLC <br /> Primary Local Business Address: 123 SUMMER LAKE DR. <br /> Local Address City/State/Zip: CARY, NC 27513 <br /> Telephone number at local base of operations: 1-800-380-7909 <br /> Name of Owner/Contact erson: CAROL VARSANO <br /> Contact Email Address: <br /> Main Office/Owner/Conta1 t Person Address: 123 SUMMER LAKES DR. <br /> Main Office City/State/Zip: CARY, NC 27513 <br /> Telephone number at maih office: 1-800-380-7909 <br /> Operating Business/Trade Name: FIRST CHOICE MEDICAL TRANSPORT, LLC <br /> 1 <br /> Application Attachments Required <br /> (See Orange County Franchise Ordinance for Additional Details) <br /> *Place a check mark in the check-box to indicate that the attachment has been included in the application. <br /> 1. ❑ N/A Certified copy of an assumed name certificate if applicant does business under a trade <br /> name AND trade name does not appear on the Articles of Incorporation or Charter. <br /> 2. ❑ Certiiied copy of Articles of Incorporation and/or Charter. <br /> 3. gl Applicant's resume' of training and experience for the applicable service. <br /> 4. Li A full description of the type and level of service to be provided including the location <br /> of the place or places from which it is intended to operate, the manner in which the public will be able to <br /> obtain assistance and how the vehicle will be dispatched. <br />