Laserfiche WebLink
1 <br /> Q INDIAN RIVER COUNTY <br /> 7 y <br /> DEPARTMENT OF EMERGENCY SERVICES <br /> APPLICATION FOR <br /> R <br /> CERTIFICATE OF PUBLIC CONVENIENCE AND NECES - lw (COPgI) <br /> � _ A� Sen cor��Coc.�.r�� �('9ec�cm RA�L� g• !•� ��, <br /> APPLICATIOhI PES $`'100 00 APPLIES TO INITIAL APPLICATIONS ONLY. r <br /> If payment applicable, make check payable to IN RIVER COUNTY R.I . <br /> This is a new application; fee is:attached. <br /> This is a renewal of our present COPCN. <br /> ❑ This is a renewal of our present COCPN with ownet'ship or classifitAfich changes. <br /> 1. 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 nduct;a pre- <br /> hospital EM ALML-S service. i <br /> Class E! Q _BLS ALS <br /> Agencies that provide nonremergency`ambitllance inter-facility m . ical transpart <br /> at the ALS/BLS level. <br /> Class C 0_BLS _ALS <br /> Agencies that provide non-emergency ambulance inter-facility medical transports <br /> which require.special clinical capabilities and require a physician's rder. <br /> Class D ❑_BLS ALS <br /> Agencies that provide non-emergency ambulance medical transpo limited to <br /> out of county transfers. <br /> Class E Wheelcfiair ,WheefchaitlStretcfieir_]lLAmbul` tory Transport <br /> Agencies at provide wheelchair transportation service only when said services <br /> are paid for in part or in whole either directly or indirectly with gover�r ent funds. <br /> Class Ell O Wheelchair Wheelchair/Stretcher Ambulator Transport <br /> Agencies that provide wheelchair vehicle service where said servicks aria not paid <br /> for in part or in whole either directly or indirectly with government funds. <br /> I <br /> U:Zeth\8eth Casano E1lXlCMRENEWAL PACKETSICOPCN Application rev:2013.doc I j <br /> 54 <br />