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GRANT APPLICATION ep <br /> A 01 <br /> GE. RTIFICA110N ON i a ;7 r CAGE <br /> • <br /> 1K , BARTOW CLERK <br /> FLORIDA DEPARTMENT OF HEALTH f — C <br /> Bureau of Emergency Medical Services <br /> IJ 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 : 180027 in Street Vero Beach Florida 32960 <br /> Telephone : (772 226 -3900 <br /> Federal Tax ID Number ( Nine Digit Number) . VF 59 as 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 sig � 04NF s <br /> acknowledges and assures that the County shall comply fully with the condi <br /> outlined in the Florida EMS County Grant Application . <br /> Signature : Date : 10 - 04 - • o °, <br /> : Cc ; <br /> Printed Name : Bob Solari io - � -�� ;w; <br /> Position Title : Chairman , Board of County Commissioners s <br /> 3 . Contact Person : (The individual with direct knowledge of the project on a d ? NF <br /> day basis and has responsibility for the implementation of the grant activities . This <br /> person is authorized to sign project reports and may request project changes . The <br /> signer and the contact person may be the same . ) <br /> Name : Brian S . Burkeen <br /> Position Title : Assistant Chief <br /> Address : 4225 43 " Avenue Vero Beach Florida 32966 <br /> Telephones (772).. 226=a3864 Fax Number: 772) 226 -3868 <br /> E- 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 County Fire Rescue <br /> DH Form 1684 , Rev. June 2002 <br />