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Orange County Emergency Management <br /> P. O. Box 8181, Hillsborough, NC 27278 5 <br /> Office (919) 968-2050 Fax (919) 968-4066 <br /> APPLICATION FOR FRANCHISE <br /> AMBULANCE * EMS * MEDICAL RESPONDER * RESCUE <br /> Date of Application• <br /> Name of Applicant: AAA 041- 1A15- <br /> Primary Local Business Address: / qc> ,3 6. 01, P3 cyy f cyP� <br /> Local Address City/ State/Zip: tO W Q 9,4!1A 270q <br /> Telephone number at local base of operations: <br /> Name of Owner/ Contact Person: -TE Fr L. - Q A P_T5:/z S <br /> Main Office/ Owner/ Contact Person Address: 1q0 $' 6 Milo Okl*)Rjd Nw� <br /> Main Office City/ State /Zip: /�ltQ NA ,w� 11/C., r�- 77p,41 <br /> Telephone number at main office: 9982 <br /> Operating Business /Trade Name: A A A 7e�AS�po� T fjll� <br /> Please Mark Category of Franchise Applying For: <br /> (A separate application must be completed for each general category of service) <br /> Ambulance Emergency Medical Medical Responder Rescue <br /> [ Ls non-emergency [ ] BLS transport [ ] First Responder , ( ] Extrication <br /> [ ] ALS non-emergency [ ] ALS non-transport [ ] EMT Responder [ J High / Low Angle <br /> [ ] ALS transport [ ] 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 />