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2016-141
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Last modified
9/16/2016 11:49:47 AM
Creation date
9/16/2016 11:49:47 AM
Metadata
Fields
Template:
Official Documents
Official Document Type
Application
Approved Date
09/13/2016
Control Number
2016-141
Agenda Item Number
15.A.3.
Entity Name
Florida Department of Health
Subject
Emergency Medical Services Program
EMS Grant Application
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EMS COUNTY GRANT APPLICATION <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Qp� � Emergency Medical Services.Program <br /> Complete all items <br /> ID. Code The State EMS Program will assign the ID Code— leave this blank C50 <br /> 1. Count Name: Indian River Count <br /> Business Address 1800 27th Street <br /> Vero Beach, FL 32960 <br /> Telephone 772-226-3900 <br /> Federal Tax ID Number Nine Digit Number VF 59-60006764 <br /> 2. Certification: (The applicant signatory who has authority to sign coptracts,,,9rants, and other legal <br /> documents for the county) I certify that all information and data in tf�i�;£IS9��`�3( t .,Grant application and <br /> its attachments are true and correct. My signature acknowledges' d� ures <br /> o. the County shall <br /> comply fully with the conditions outlined in the Florida EMS Cou -Gr vp tio�r'; <br /> Signature: G Da* 09/13/2016 <br /> Qc.c.c <br /> Printed Name Bob Solari e <br /> Position Title. Chairman, Board of County Commis` rs <br /> 3. Contact Person: (The individual with direct knowledge of the proJec l�w. �. y-to-day basis and has <br /> responsibility for the implementation of the grant activities. This person is authorized to sign project <br /> reports and may request project changes The signer and the contact person may be the same ) <br /> Name Brian Burkeen <br /> Position Title Assistant Chief <br /> Address 4225 43rd Avenue <br /> Vero Beach, FL 32967 <br /> Telephone 772-226-3864 Fax Number 772-226-3868 <br /> E-mail Address bburkeen@ircgov.com <br /> 4. Resolution: Attach a resolution from the Board of County Commissioners certifying the grant funds <br /> will improve and expand the county pre-hospital EMS system and will not be used to supplant current <br /> levels of county expenditures. We cannot process for funds without a current resolution <br /> 5. Budget: Complete a budget page(s) for each organization to which you shall provide funds <br /> List the organization(s) below (Use additional pages if necessary) <br /> Indian River County Fire Rescue <br /> DH 1684, December 2008 64J-1 015, F.A.0 <br /> ATTEST: <br /> Jeffrey R. Smith Cl-erk of Cour and <br /> Ccmptrol e <br /> BY: <br /> p y er <br />
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