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EMS COUNTY GRANT APPLICATION <br />FLORIDA DEPARTMENT OF HEALTH <br />Emergency Medical Services Program <br />Complete all items <br />ID. Code (The State EMS Program will assign the ID Code – leave this blank) C40 <br />1. County Name: Indian River County <br />Business Address 1800 27th Street <br />Vero Beach, FL 32960 <br />Address' 4225 43rd Avenue <br />Telephone 772-226-3900 <br />Federal Tax ID Number (Nine Digit Number). VF 59-60006764 <br />2. Certification: (The applicant signatory who has authority to sign contracts.,grants,. and other legal <br />documents for the county) I certify that all information and data in this EMS'couiltygr' t pplication and <br />its attachments are true and correct. My signature acknowledges and autres thane E.ounty shall <br />comply fully with the con s outlined i%4he FloridaoELMS County Graix€A�atib�ra. <br />Signature: • <br />J..J c—C p,.C.a �; 404 = ! - e Deceither 8 , 20 <br />do ,.\fi. <br />Printed Name. Bob Solari <br />Position Title Chairman, Board of County Commissionerk• <br />t` ,„ . <br />3. Contact Person: (The individual with direct knowledge of the project ort-itiAti...§icray basis and has <br />responsibility for the implementation of the grant activities This person is authorized to sign project <br />reports and may request project changes The signer and the contact person may be the same ) <br />Name Brian Burkeen <br />Position Title Assistant Chief <br />Address' 4225 43rd Avenue <br />Vero Beach, FL 32967 <br />Telephone. 772-226-3864 <br />Fax Number. 772-226-3868 <br />E-mail Address bburkeen@ircgov.com <br />4. Resolution: Attach a current resolution from the Board of County Commissioners certifying the grant <br />funds will improve and expand the county pre -hospital EMS system and will not be used to supplant <br />current levels of county expenditures We cannot process for funds without a current resolution <br />5. Budget: Complete a budget page(s) for each organization to which you shall provide funds <br />List the organization(s) below (Use additional pages if necessary) <br />Indian River County Fire Rescue <br />DH 1684, December 2008 <br />64J-1 015, F.A.0 <br />1 <br />DH 1684, December 2008 <br />64J-1 015, F.A.0 <br />1 <br />