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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 2r Street Vero Beach Florida 32960 ••• oSS�ONERS;# ; <br /> . . <br /> o : <br /> Federal Identification number VF 59-6000674 � . ¢; <br /> :z :aa <br /> Authorized Official : G Gt�� _ : = : � _ <br /> a <br /> //Signature Date <br /> Gary C. eeler, Chairman Board of County Commissimi's, . ., •���4° <br /> Type Name and Title •; � ; °a <br /> rrnwussnuo "y"„ A <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 /> 64-25-60-00-000 N N2000 7 <br /> Federal Tax ID : VF_ _ _ _ _ _ _ _ _ <br /> Grant Beginning Date: October 1 , Grant Ending Date: September 30, <br /> DN Form 1767P, Rev, June 2002 <br />