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II. <br />1. <br />2. <br />3. <br />4. <br />NAME <br />COMPANY DETAILS ^� <br />NAME OF AMBULANCE SERVICE:1(1CI1C\r ?)Wk.( SYO(eS <br />ublhc Sc <br />Rel <br />MAILING ADDRESS: (190j1 NI • NIA <br />CITY IOdkan (R1Vei TOKSCOUNTY Sc1C\1Ckt1 `RIV -( <br />ZIP CODE: Q b3 BUSINESS PHONE: '1-107- as 1 -a 45\ <br />TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />Muc)tctra.\\ANI <br />MANAGER'S NAME: M'CcnQe\ ,UCc O CAk0ci lblt'ec4Of <br />, <br />ADDRESS: 0001 N. �M -T A n CII A CI I\ VC( c•Y1� CXeSif 33%3 <br />PHONE #: %-10; - cg. 1-,45I <br />PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PART ERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (atta h a <br />separate sheet if necessary): <br />ADDRESS POSIT! N <br />Ni A <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />N <br />►A <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 2 <br />29 <br />