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PtMENr INDIAN RIVER COUNTY <br />DEPARTMENT OF EMERGENCY SERVICES <br />of ®o <br />�FN�SEP APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />SCS., I DATE: ---) 131 1 ` (U <br />1 <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <br />❑ yhis is a new application; fee is attached. <br />This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COPCN with ownership or classification changes. <br />;CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A V BLS _ZALS <br />Governmental entities that use advanced life support vehicles to conduct a pre - <br />i hospital EMS ALS/BLS service. <br />Class B ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transports <br />which require special clinical capabilities and require a physician's order. <br />Class D ❑ _BLS _ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said services <br />are paid for in part or in whole either directly or indirectly with government funds. <br />,Class E1 ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair vehicle service where said services are not paid <br />for in part or in whole either directly or indirectly with government funds. <br />IS-.01WV I—SO918b <br />S3 30 1N3M1121VW3 <br />d3Q <br />03AI3338 <br />U-\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc 1 76 <br />I <br />