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II. COMPANY DETAILS <br /> 1. NAME OF AMBULANCE SERVICE: vF `T7-1c m`ASuRC <br /> MAILING ADDRESS: I47-7/ SvN/ �j�r►ivRLs T. <br /> CITY <br /> �� ��`i; 1_.tJGi6- COUNTY <br /> ZIP CODE: BUSINESS PHONE: X74- <br /> 2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br /> etc.)-. <br /> 3. MANAGER'S NAME: AJlCCQA,S Ko IA-2 � <br /> ADDRESS: - 02' SW 3 i;4.i M OKII la-1,er ►. Lyuc, i�'d. 3y`3�y <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 ADDRESS POSITION <br /> ZAeoKoS R-)( 'SL ly ti= S;. Pr-,e-,S/b 6-AlT <br /> RP�7 ST.. WACE r--(— 3jqeit <br /> 5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br /> REFERENCES <br /> NAME ADDRESS PHONE# <br /> U:\Brianb\COPCN\COPCN Application rev.2013.doc <br /> 43 <br />