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12. PLEASE LIST ALL HOSPITALS AND OTHER EMERGENCY AGENCIES WITH <br />WHICH YOU HAVE DIRECT RADIO COMMUNICATIONS: <br />FROM AMBULANCE FROM BASE STATION <br />All State Hospitals and Medical Stations Sebastian River Medical Center <br />Central Dispatch Indian River Memorial Hospital <br />All Law Enforcement Lawnwood Regional <br />Fire Apparatus <br />Municipal, County and Constituency Agencies <br />13. ATTACH THE FOLLOWING COMPLETED DOCUMENTS WITH APPLICATION: <br />A. <br />B. <br />VEHICLE INFORMATION (form provided) <br />PERSONNEL ROSTER (form provided) <br />C. INSURANCE VERIFICATION (provide <br />copy of policy, coverage limits must be shown on policy). <br />D. COPY OF STANDARD OPERATING <br />PROCEDURES <br />E. INCLUDE A COPY OF MEDICAL <br />PROTOCOLS <br />Attached <br />Attached <br />Attached <br />On File in <br />Commission Office <br />On File in <br />Commission Office <br />14. I hereby certify that this service will provide continuous service on a 24-hour, 7 - <br />day week basis. I, the undersigned representative of the above service, do hereby attest <br />that my service meets all of the requirements for operation of an ambulance service in the <br />state as provided in Chapter 401, Part III, Florida Statutes, Chapter 64E-2, Florida <br />Administrative Code, and that I agree to comply with all the provisions of Chapter 304, <br />life support services. <br />I further acknowledge that discrepancies discovered during the effective period of <br />the Certificate of Public Convenience and Necessity will subject this service and its <br />authorized representatives to corrective action and penalty provided in the referenced <br />authority. <br />171 <br />