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DEPARTMENT OF HEALTH <br /> EMS GRANT PROGRAM <br /> REQUEST FOR GRANT FUND DISTRIBUTION <br /> In accordance with the provisions of Section 401 . 113(2)(a) , F . S . , the undersigned <br /> hereby requests an EMS grant fund distribution for the improvement and expansion of <br /> pre-hospital EMS . <br /> DOH Remit Payment To : <br /> Name of Agency: Indian River County Board of County Commissioners <br /> ", COMM/ S <br /> t" <br /> Mailing Address : 1801 27Stmt Vero Beach Florida 32960 ,.��� • . • " ' " ' S •�� <br /> fee <br /> a <br /> Federal Identification number VF 59=6000674 <br /> Authorized Official: 5 <br /> Signatur Date =?O�• O` <br /> e h E. Flescher Chairman Board of CountyCommissione <br /> Type Name and Titleof Stu <br /> `"•• R COUNo""°° <br /> Sign and return this page with your application to: <br /> Florida Department of Health <br /> BEMS Grant Program <br /> 4052 Bald Cypress Way, Bin C18 <br /> Tallahassee, Florida 323994738 <br /> Do not write below this line. For use by Bureau of Emergency Medical Services personnel only <br /> Grant Amount For State To Pay: $ Grant ID: Code : <br /> Approved By : <br /> Signature of EMS Grant Officer Date <br /> State Fiscal Year . <br /> Organization Code E. O. OCA Obiect Code <br /> 64-25gso-00go000 N_ N2000 7 <br /> Federal Tax ID: VF_ _ _ _ _ _ _ _ _ <br /> Grant Beginning Date: October 1 , Grant Ending Date : September 30, <br /> DH Form 1767P, Rev, June 2002 <br /> 14 <br />