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Orange County Emergency Management <br />P. O. Box 8181, Hillsborough, NC 27278 <br />Office (919) 968-2050 Fax (919) 968-4066 <br />APPLICATION FOR FRANCHISE <br />AMBULANCE * EMS * MEDICAL RESPONDER ~` RESCUE <br />6 <br />Date of Application: ~~/ ~ ~~ <br />Name of Applicant: _~ <br />Primary Local Business Address <br />Local Address City /State /Zip: <br />S <br />Telephone number at local base of operations: ~~1Q 1 30~--~(~ 3~_ (, ~r,/~. Ct~So <br />Name of Owner /Contact Person: <br />Main Office !Owner /Contact Person Address: <br />Main Office City /State /Zip: <br />Telephone number at main o1 <br />Operating Business /Trade ~ <br />Please Mark Category of Franchise Applying For: <br />(A separate application must be completed for each general category of service) <br />Ambulance <br />[~ BLS non-emergency <br />[ ]ALS non-emergency <br />Emergency Medical <br />[ ]BLS transport <br />[ ]ALS non-transport <br />[ ]ALS transport <br />Medical Responder <br />[ ]First Responder [ <br />[ ]EMT Responder [ <br />C <br />[ <br />Rescue <br />] Extrication <br />] High /Low Angle <br />] Confined Space <br />] Trench, Collapse <br />] Swiftwater <br />] Underwater <br />Application Attachments Required <br />(See Orange County Franchise Ordinance for Additional Details) <br />1. Certified copy of Articles of Incorporation and / or Charter <br />2. Applicant's resume of training and experience category of service applying for franchise <br />3. Financial statement pertaining to [proposed] operations in Orange County <br />4. Copy of organization by-laws (if applicable) <br />5. Copy of organization standard operating procedures <br />6. Current roster of all members and employees, including name, address, and NCDL number. <br />7. Proposed fee schedule for service in Orange County <br />