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5. E Financial statement pertaining to (proposed) operations in Orange County. <br /> 6. ❑ A I st of radio frequencies the applicant is authorized to operate on, and a copy of the <br /> FCC license(s) in the na lie of the person providing the service. <br /> 7. ❑ A cescription of the applicant's capability to provide twenty-four hour coverage, seven <br /> days per week for the di trict covered by the franchise applied for. <br /> 8. ❑ An accurate estimate of the minimum and maximum times for a response to calls <br /> within the district covere by the franchise applied. <br /> 9. ❑ A vyritten plan detailing how the applicant will furnish credentialed personnel and a <br /> current roster of all credentialed personnel with a list of their credentials. <br /> 10.❑ A copy of the applicant's written standard operating procedures including but not <br /> limited to the manageme t of equipment, supplies, and medications. <br /> 11.0 N/A Co y of organization by-laws (if applicable). <br /> 12. ❑ Ro ter of all members and employees, including name, address, and NCDL number. <br /> 13. ❑ Lis all vehicles owned and operated by applicant. <br /> 14. ❑ Proposed fee schedule for service in Orange County. <br /> CERTIFICATIONS <br /> *Provide initials in each Certification blank to indicate agreement to each statement <br /> I certify on behalf of the nIrmed franchise applicant the following: <br /> ( ,1 1. That the information contained within and any attachments provided is true and correct and <br /> //�� / to the best of my knowledge; <br /> C12.2. That the fr nchise applicant is compliance with North Carolina General Statutes 131E, Article <br /> 7; <br /> LA; 3. That the applicant shall provide notices to Orange County Emergency Services of any <br /> changes to the information provided in this Application within five (5) days of any changes <br /> and/or any relinquishment of the franchise; <br /> ..0 / 4. That I am the duly authorized agent of the Board and have been authorized to submit this <br /> application and certification to the Orange County; and <br /> 5. That any in ormation found to be false or <br /> misleading may be grounds for termination of the <br /> franchise and the franchise agreement. <br /> 1'' <br /> Authorizing Name/Title: Cl \f,)q ScZI� Q ��.����,( � a�� �L c e )- _ CU Ot,Uf iar <br /> C�' <br /> 1 4 J <br /> Authorizing Signature: <br /> Date: e/r) <br />