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151.&0 63 <br /> 15 . AZ. <br /> AO « -� 40 <br /> GRANT APPLICATION <br /> _FLORIDA - DEPARTMENT OF HEALT-H_ -- - -_ - _ - -- -- - --- - _ - - -- <br /> - - Bureau of Emergency Medical Services <br /> Complete all items <br /> ID. Code (The State Bureau of EMS will assign the ID Code - leave this blank) C <br /> 1 . County Name: Indian River County <br /> Business Address . 1801 2r Street Vero Beach Florida 32960 <br /> Telephone : (772) 226-3900 <br /> Federal Tax ID Number ( Nine Digit Number) . VF 59 - 60006764 <br /> 2. Certification : (The applicant signatory who has authority to sign contracts , grants , <br /> and other legal ' documents for the county) I certify that all information and data in this <br /> EMS county grant application and its attachments are true and correct. My signature <br /> acknowledges and assures that the County shall comply fully with the conditions <br /> outlined in the F rida EW County Grant Application . <br /> °aql <br /> Signature : °° ik " z, 5 - 0 I <br /> Printed Na Jose h E. Flescher ,•`�.•• ' ' ' . 'yo <br /> Position TitNror Chairman, Board of County C , 'on <br /> iU ' ILK <br /> a <br /> 3. Contact Person : (The individual with direct knd el dge oj46n a day4o- <br /> day basis and has responsibility for the implementd4iork of th ities . This <br /> person is authorized to sign project reports and may' • anges. The <br /> signer and the contact person may be the same . ) ""••NRIVER „,�••° <br /> Name: Brian S. Burkeen <br /> Position Title: Assistant Chief <br /> Address : 4225 43m Avenue Vero Beach Florida 32967 <br /> Telephone : 772 226-3864 Fax Number: 772) 2264868 <br /> &mail Address : bburkeen irc ov.com <br /> 4. Resolution: Attach a current resolution from the Board of County Commissioners <br /> certifying the grant funds will improve and expand the county pre-hospital EMS system <br /> and will not be used to supplant current levels of county expenditures . <br /> 5. Budget: Complete a budget page(s) for each organization to which you shall provide <br /> funds . <br /> List the organization( s) below. (Use additional pages if necessary) <br /> Indian River Cou Fire Rescue <br /> DH Form 1684, Rev. June 2002 <br />