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EMD CENTER RENEWA L A PPL ICA TION <br />Effective: 8/1/2014 <br />EMDCENTER NAME:________________________________________________ PROVIDER NUMBER:____________________ <br />ENDORSEMENTS <br />We, the undersigned, recommend this EMD Center for renewal by the North Carolina Office of EMS. We fully approve, support, and endorse this application to the <br />North Carolina Office of EMS with thorough knowledge and understanding of our respective roles and responsibilities in maintaining an EMD Center within our <br />EMS System in the State of North Carolina pursuant to the rules of the North Carolina Medical Care Commission. <br />EMDCENTER DIRECTOR <br />Type/Print Name Signature Date <br />EMS SYSTEM ADMINISTRATOR <br />Type/Print Name Signature Date <br />SYSTEM MEDICAL DIRECTOR <br />Type/Print Name Signature Date <br />*COUNTY MANAGE R <br />Type/Print Name Signature Date <br />*The County Manager’s signature is not required when through written delegation or resolution, the system administrator has been delegated authority to act on <br />behalf of the county. If the county manager or system administrator has changed since last submission, a new letter from the county is required. <br /> <br /> <br /> <br />BE PREPARED TO PRESENT SUPPORTING DOCUMENTATION UPON REQUEST <br />EMD Center Renewal Effective 8/1/2014 <br />DHHS/DHSR/OEMS 4917 <br />Page 3 of 3 <br />DocuSign Envelope ID: 0123867B-484A-40EF-9EC6-2607BAF583F8 <br />0680960Orange County Emergency Services <br />Dr. Jane Brice <br />Kevin G. Medlin <br />Bonnie Hammersley <br /> <br />Kimberly K. Woodward  <br />