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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 /> Mailing Address : 1800 27th Street Vero Beach Florida 32960 <br /> Federal Identification number VF 59-6000674 C0 �1Mis.s <br /> °>��s�. • ip <br /> Authorized Official : <br /> Signature Daite ? •' o <br /> Bob Solari Chairman Board of County Comifiisiione <br /> Type Name and Title <br /> ' ® Jj •_• _�a`� <br /> *00 <br /> .10 <br /> Sign and return this page with your application to: •''9 � COIa•�° <br /> Florida Department of Health ob anamunze• <br /> BEMS Grant Program <br /> 4052 Bald Cypress Way, Bin C18 <br /> Tallahassee, Florida 32399- 1738 <br /> Do not write below this line. For use by Bureau of Emergency Medical Services Dersonnel 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 Object Code <br /> 64-25-60-00-000 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 /> NATE OF FLORIDA —�_ ••• COM <br /> SS <br /> INDIAN RIVER CQUNTY '•.••0���• ' • • ° • • • • • / . ,/Q� <br /> THIS IS TO CER Y THA THIS IS <br /> ATRUE AND C RR CTC P OF- <br /> T <br /> F- <br /> THE ORI O ILE I Ir <br /> OFFICE ; # i <br /> C <br /> Y K . 8A R L F_ R ,•• <br /> DATE f1 �t W <br /> opts , �66i • 'r•.` *• <br /> • •• <br />