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ATM�r INDIAN RIVER COUNTY <br />QvQPs-� F,9 <br />DEPARTMENT OF EMERGENCY SERVICES <br />CD <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: Falck Southeast II Corp d/b/a All County Ambulance <br />DATE: February 1, 2016 <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <br />❑ This is a new application; fee is attached. <br />19 This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COPCN with ownership or classification changes. <br />I. CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ _BLS _ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B 04 /BLS ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transports <br />which require special clinical capabilities and require a physician's order. <br />Class D ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E 1% / Wheelchair / Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said services <br />are paid for in part or in whole either directly or indirectly with government funds. <br />Class E1 ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair vehicle service where said services are not paid <br />for in part or in whole either directly or indirectly with government funds. <br />C:\Users%4sa1vesen\Des1dop\1RFD COPCN 2016\ACA IR COPCN 2016.doc 1 <br />107 <br />