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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: 05l ~l ~3 <br />Name of Applicant: ~~{f~~ /ate. <br />Primary Local Business Address:~4(,h t~~ <br />Local Address City /State /'Zip: ~~~ _ U <br />Telephone number at local base of operations: <br />Name of Owner /Contact Person: ~~ <br />Main Office /Owner /Contact Person Address: <br />Main Office City /State /Zip: <br />Telephone number at main of <br />Operating Business !Trade <br />.~~~ ( <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 />Emeraency Medical <br />[ ] BL5 transport <br />[ ]ALS non-transport <br />[ ]ALS transport <br />Medical Resnonder <br />[ ]First Responder <br />[ ]EMT Responder <br />Rescue <br />] Extrication <br />] High !Low Angie <br />] Confined Space <br />] Trench, Collapse <br />] Swiftwater <br />] Underwater <br />Application Attachments Required <br />(See Orange County Franchise Ordinance for Additional Details) <br />t. Cert~ed 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 ail members and employees, including Warne, address, and NCDL number. <br />7. Proposed fee schedule for service in Orange County <br />