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® IV. ADDITIONAL INFORMATION REQUIRED TO DE SUBMITTED <br /> WITH THIS APPLICATION: <br /> 1. Factual Statement indicating the public need and services, including studies <br /> supporting the demonstrated demand and feasibility for theproposed <br /> services)and deficiencies in existing services, and any Other pertinent data <br /> you wish to::be considered. <br /> 2. 'Factual statement of the proposed services to be provided, lilt &ng type of <br /> service, hours and days of operation, market to be served, geographic areas <br /> to be serviced, and any other pertinent data you wish to be considered. <br /> 1 <br /> 3. Factual Statementindicating the ability of the applicant to manage and <br /> provide the proposed services including the management plan,imaintenance <br /> facilities, insurance program, accounting system, system for handling <br /> complaints, system for handling accidents and injuries, system for providing <br /> the county monthly operating repor#s-and any other pertinent data you wisht <br /> be considered. <br /> 4. Copy of Standard Operating Procedures. <br /> 5. Copy of Medical Protocol$. <br /> ✓$., Copy of your insurance policy mint show coverage limits— <br /> ✓7. Vehicle Information.For each vehicle provide the following: f <br /> a. Make, Model, Year, Manufacturer <br /> b, Mileage <br /> a. VIN <br /> d. Tag Number <br /> e. Passenger capacity,(E/E1 classification) <br /> f. Indroate ALS/BLS(A-D classification) <br /> V/8. Personnel Roster. For each employee provide-the following: <br /> a. Name— Last, First and Middle Initial <br /> b. Driver's License # (if commercial, specify class) & Expiration Date <br /> ADDITIONAL INFO REQUIRED FOR A-D classifications <br /> c. Emergency Medical Service Certification and # (EMT or Paramedic) <br /> d. Expiration date of Certification <br /> e. Whether or not has an Emergency Vehicle Operation Certificate. <br /> /9. Fee Schedule Including: <br /> Service Type, Base Rate, Mileage, Waiting and Special Charges <br /> WBeNBeth Casano EOCICOPCNIRENEWAL PACKETMOPCN Application rev.2013.doc 4 <br /> 57 <br />