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i <br /> M '� INDIAN RIVER COUNTY t <br /> DEPARTMENT OF EMERGENCY SERVICES' <br /> APPLICATION FOR <br /> CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COP <br /> CN) <br /> AI=PL►C` �I -� CL DATE <br /> APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATION'S ONLY. <br /> If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <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 ownership or classificatidn changes. <br /> 1. CLASSIFICATION OF CERTIFICATE REQUESTED <br /> i <br /> Please check applicable boxes and options. <br /> i <br /> Class A ❑ BLS ALS <br /> Governmental en_tities 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 ❑ VBLS _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 transpoits limited to <br /> out of county transfers. <br /> Class E Wheelchair Wheelchair/Stretcher Ambulatory Transport <br /> Agencies ha 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 /> U:1BethOeth Casano EMCOPCNIRENEWAL PACKETSICOPCN Application rev.2013.doc <br /> 74 <br />