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II. COMPANY DETAILS <br />1. NAME OF AMBULANCE SERVICE: 4\� s n'Z��9�� <br />MAILING ADDRESS: <br />CITYa\�.��rz COUNTYj\Q_�CC�X <br />ZIP CODE: 3Z— BUSINESS PHONE: <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />3. MANAGER'S NAME: on,,,,, cw�- r <br />ADDRESS: t -c <br />PHONE #: _C3��� <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME ADDRESS POSITION <br />a <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE # <br />lin\�►-� 1 •:�s� X1?s Jas �"r\��n�:\�y,a�, <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 2 <br />84 <br />