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II. COMPANY DETAILS <br />1. NAME OF AMBULANCE SERVICE: <br />MAILING ADDRESS: <br />CITY 4� _COUNTY <br />ZIP CODE: _'�Za,- BUSINESS PHONE:1 <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />3. MANAGER'S NAME: t ,`j`,4w. (N\c r <br />ADDRESS. �. �.cG� ' .bf <br />PHONE #; <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME <br />ADDRESS POSITION <br />5. PROVIDE DAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE# <br />�&& .akC <br />i 1� ].9L � C'CA 1 r.�nl� AL -1 \I,, QiC�L x'40? -,Z- w <br />WBeth)Beth Casano E0=0PCNIRENEWAL PACKETSICOPCN Appfication.doc <br />84 <br />