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FLORIDA 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 hereby <br /> requests an EMS grant fund distribution for the improvement and expansion of pre-hospital <br /> EMS. <br /> DOH Remit Payment To: <br /> Name of Agency: <br /> Mailing Address: <br /> Federal Identification number Fed ID <br /> Authorized Official: <br /> Signature Date <br /> Type Name and Title <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 32399-1738 <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.Q.. 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 /> 5 <br />