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GRANT APPLICATION <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Bureau of Emergency Medical Services <br /> 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: 1840 25th Street Vero Beach Florida 32960 <br /> Telephone: (772) 567-2154 <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 in this <br /> EMS county grant application and its attachments are true and correct. My signature <br /> acknowledges and assures that the County shall comply fully with the conditions <br /> outlined in the Florida EMS County Grant Application. <br /> Signature: Date: <br /> Printed Name: Arthur R. Neuberger <br /> Position Title: Chairman, Board of County Commissioners <br /> 3. Contact Person: (The individual with direct knowledge of the project on a day-to- <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: 1840 25 Street Vero Beach Florida 32960 <br /> Telephone: 772 562-2028 X 3015 Fax Number: 772 770-5147 <br /> E-mail Address: bburkeen@ircgov.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 Department of Emergency Services <br /> DH Form 1684, Rev.June 2002 <br />