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12. PLEASE LIST ALL HOSPITALS AND OTHER EMERGENCY AGENCIES WITH <br />WHICH YOU HAVE DIRECT RADIO COMMUNICATIONS: <br />FROM AMBULANCE FROM BASE STATION <br />All State Hospitals and Medical Stations <br />Central Dispatch <br />All Law Enforcement <br />Fire Apparatus <br />Municipal, County and Constituency Agencies <br />Sebastian River Medical Center <br />Indian River Memorial Hospital <br />Lawnwood Regional <br />13. ATTACH THE FOLLOWING COMPLETED DOCUMENTS WITH APPLICATION: <br />A. VEHICLE INFORMATION (form provided) Attached <br />B. PERSONNEL ROSTER (form provided) Attached <br />C. INSURANCE VERIFICATION (provide <br />copy of policy, coverage limits must be shown on policy). Attached <br />D. COPY OF STANDARD OPERATING On File in <br />PROCEDURES Commission Office <br />E. INCLUDE A COPY OF MEDICAL On File in <br />PROTOCOLS Commission Office <br />14. I hereby certify that this service will provide continuous service on a 24-hour, 7 - <br />day week basis. I, the undersigned representative of the above service, do hereby attest <br />that my service meets all of the requirements for operation of an ambulance service in the <br />state as provided in Chapter 401, Part III, Florida Statutes, Chapter 64E-2, Florida <br />Administrative Code, and that I agree to comply with all the provisions of Chapter 304, <br />life support services. <br />I further acknowledge that discrepancies discovered during the effective period of <br />the 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. <br />49 <br />