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9. Fee Schedule Incl: Service Type, Base Rate, Mileage, Waiting & Special Charges <br /> IV. NOTARIZED STATEMENTS Fill in Statements as applicable. <br /> E or E1 APPLICANTS ; <br /> the representative of <br /> �y Applicant Name <br /> .fit r - -i a �,e,/�� , do hereby attest that the <br /> Business Name of Service <br /> above named service meets all the requirements of, and that I agree to comply with, all <br /> applicable provisions of Chapter 304, Life Support and Wheelchair Services. <br /> A-D APPLICANTS <br /> the representative of <br /> Applicant Name <br /> 1411 , do hereby attest that <br /> Business Name of Service <br /> the above named service will provide continuous service on a 24-hour, 7-day week basis. I do <br /> hereby attest that the above named service meets all the requirements for operation of an <br /> "'ambulance service in the State of Florida as provided in Chapter 401, Part III, Florida Statutes, <br /> Chapter 64E-2, Florida Administrative Code, and that I agree to comply with all the provisions <br /> of Chapter 304, Life Support Services. <br /> ALL APPLICANTS <br /> I further acknowledge that discrepancies discovered during the effective period of the <br /> 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 and that to the best of my knowledge, all statements on this application are <br /> true and correct. <br /> APPLICANT <br /> �SI ATURE DATE <br /> Before me personally appeared the said (i who says that he/she <br /> executed the above instrument of his/her own free will and accord, with full knowledge of the purpose <br /> thereof. Sworn and subscri eco in Ty presence this i- day of „ , r201 ? <br /> My commission expires c- p; <br /> fi NOTARY PUBLIC <br /> ME-LEP <br /> , ,r" r. <br /> ® ` Pl)ary Fub ic, :< of Florida <br /> Corti r psi+ is DUg37/366 <br /> ;r comm.exi;i;pt May 2:3,201 <br /> C:\Users\jsalvesen\Documents\AII County 2013 Idian river Copcn Application.doc 5 <br /> 139 <br />