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IV. ADDITIONAL INFORMATION REQUIRED TO BE SUBMITTED <br />WITH THIS APPLICATION: <br />RENEWAL APPLICANTS FOR CLASSES A -D NEED ONLY #'s 4 - 9 _ <br />RENEWAL APPLICANTS FOR CLASSES E AND E-1 NEED ONLY #'s 6 - <br />1. Factual Statement indicating the public need and services, including studies <br />supporting the demonstrated demand and feasibility for the proposed <br />service(s) and deficiencies in existing services, and any other pertinent data <br />you wish to be considered. <br />2. Factual statement of the proposed services to be provided, including type of <br />service, hours and days of operation, market to be served, geographic areas <br />to be serviced, and any other pertinent data you wish to be considered. <br />3. Factual Statement indicating the ability of the applicant to manage and <br />provide the proposed services, including the management plan, maintenance <br />facilities, insurance program, accounting system, system for handling <br />complaints, system for handling accidents and injuries, system for providing <br />the county monthly operating reports and any other pertinent data you wish to <br />be considered. <br />4-5 <br />4. Copy of Standard Operating Procedures. <br />5. Copy of Medical Protocols. <br />6. Copy of your insurance policy —must show coverage limits <br />7. Vehicle Information. For each vehicle provide the following: <br />a. Make, Model, Year, Manufacturer 0 7'Q1 S IOW710 <br />b. Mileage ` 0-L c)v o <br />c. VIN# ®5'T7bkffZbcOE511�,t362y <br />d. Tag Number �f J U VM <br />e. Passenger capacity (E/E1 classification) <br />f. Indicate ALS/BLS (A -D classification) � <br />8. Personnel Roster. For each employee provide the following: <br />a. Name — Last, First and Middle Initial <br />b. Driver's License # (if commercial, specify class) & Expiration Date <br />ADDITIONAL INFO REQUIRED FOR A -D classifications <br />c. Emergency Medical Service Certification and # (EMT or Paramedic) <br />d. Expiration date of Certification <br />e. Whether or not has an Emergency Vehicle Operation Certificate. <br />9. Fee Schedule Incl: Service Type, Base Rate, Mileage, Waiting 8 Special Charges <br />U:\Beth\Beth Casano EOMCOPCMRENEWAL PACKETSICOPCN Application.doc <br />4 <br />P40 <br />