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r' <br /> INDIAN RIVER COUNTY <br /> SO9 �'` DEPARTMENT OF EMERGENCY SERVICES <br /> m <br /> APPLICATION FOR <br /> CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br /> APPLICANT NAME: WC- CARg, c)F- -rfj` 1?CaSUR6- C04t�7 .�Ne; DATE: ?-,)pj <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 /> i�f This is a renewal of our present COPCN. <br /> ❑ This is a renewal of our present COCPN 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 ® 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 j Wheelchair 'f 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 /> '"10 St Inr ejaa <br /> 3931Aa3s AjNJ983w3 <br /> JO 1N3W18i'd3Q <br /> U3A1�33� <br /> U:\Brianb\COPCN\COPCN Application rev.2013.doc 1 <br /> 42 <br />