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GRANT APPLICATION <br />FLORIDA DEPARTMENT OF HEALTH <br />Bureau of Emergency Medical Services <br />Complete all items <br />ID. Code (The State Bureau of EMS will assign the ID Code — leave this blank) C <br />1. County Name: Indian River County <br />Business Address: 1801 27t1 Street Vero Beach Florida 32960 <br />Telephone- (772) 226-3900 <br />Federal Tax ID Number (Nine Digit Number). VF 59 - 60006764 <br />2. Certification: (The applicant signatory who has authority to sign contracts, grants, <br />and other legal documents for the county) I certify that all information and data in this <br />EMS county grant application and its attachments are true and correct. My signature <br />acknowledges and assures that the County shall comply fully with the conditions <br />outlined in the Florida EMS County Grant Application. <br />Signature: Date: <br />Printed Name: <br />Position Title: Chairman, Board of County Commissioners <br />3. Contact Person: (The individual with direct knowledge of the project on a day-to- <br />day basis and has responsibility for the implementation of the grant activities. This <br />person is authorized to sign project reports and may request project changes. The <br />signer and the contact person may be the same.) <br />Name: Brian S. Burkeen <br />Position Title: Assistant Chief <br />Address: 4225 431 Avenue Vero Beach Florida 32966 <br />Telephone: (772) 226-3864 Fax Number: 772 226-3868 <br />E-mail Address: bburkeen@ircgov.com <br />4. Resolution: Attach a current resolution from the Board of County Commissioners <br />certifying the grant funds will improve and expand the county pre -hospital EMS system <br />and will not be used to supplant current levels of county expenditures. <br />5. Budget: Complete a budget page(s) for each organization to which you shall provide <br />funds. <br />List the organization(s) below. (Use additional pages if necessary) <br />Indian River County Fire Rescue <br />DH Form 1684, Rev. June 2002 <br />325 <br />