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11 • x • 12 <br /> GRANT APPLICATION 15A <br /> SCG AvlHORKINc� <br /> RVso . 2 Jags% 10 <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Bureau of Emergency Medical Services <br /> Complete all items <br /> ID. Code (The State Bureau of EMS wiU assign the ID Code — leave this blank) C <br /> 1. Counq Name: Indian River County <br /> Business Address: 180127"' Street Vero Beach Florida 32960 <br /> Telephone : 772 2264900 <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 . E� <br /> EMS county grant application and its attachments are true and correct . My s ' *° .,• <br /> acknowledges and assures that the County shall comply fully with the con s .9 <br /> outlined in the FI ida EMS County Grant Application . , ;' <br /> Signature : C Lc>/Ulf Date . 11-0640009 s <br /> Printed Name: Gq2 C . Wheeler <br /> go <br /> Position Title : Chairman, Board of County Commissioners • �yAy � <br /> •IIIIag• <br /> 3. Contact Person : (The individual with direct knowledge of the project on a day- - <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 43ra Avenue Vero Beach Florida 32966 <br /> Telephone : 772 226-3864 Fax Number: 772 2264868 <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 />