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II. COMPANY DETAILS <br /> 1. NAME OF AMBULANCE SERVICE: American Ambulance Service <br /> MAILING ADDRESS: 4227 Saint Lucie Blvd <br /> CITY Fort Pierce COUNTY Saint Lucie <br /> :ZIP CODE: 34946 BUSINESS PHONE: 772-465-1111 <br /> 2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, etc.): <br /> 3. MANAGER'S NAME: Michael DeSouza <br /> 4. ADDRESS: 4227 Saint Lucie Blvd Fort Pierce FI 34946 <br /> PHONE #: 772-465-1111 <br /> 4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, DIRECTORS, <br /> ° - AND SHAREHOLDERS, IF A CORPORATION (attach a separate sheet if necessary): <br /> NAME ADDRESS POSITION <br /> Robert F. Heffner and Charlie Maymon 6605 NW 74th Ave Miami, F133166 <br /> On File IRCFD <br /> 5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL REFERENCES <br /> NAME ADDRESS PHO <br /> John Skalko (Supply Executive) Indian River Medical 1000 37th Street Vero Beach FI 32960 772-567-4300 <br /> Candace Sherwood JVNA Hospice) 901 37th Street Vero Beach FI 32960 772-978-5620 <br /> Edwin Rojas (Adm)Atlantic Healthcare 366315 th Ave Vero Beach, FI 32960 772-567-2552 <br /> 6. FUNDING SOURCE: Private <br /> -4... 7. RATE SCHEDULE ATTACHED? YES ❑ NO ❑ N/A ❑ <br /> C:\Users\jsalvesen\Documents\American Ambulance Service 2013 Idian river Copcn Application.doc 2 <br /> 106 <br />