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vices <br />GRANT NO. <br />STATE OF FLORIDA <br />DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES <br />OFFICE OF EMERGENCY MEDICAL SERVICES <br />1991 EMERGENCY MEDICAL SERVICES COUNTY GRANT APPLICATION <br />1. Board of County Commissioners (grantee) Identification: <br />Name of County: Indian Rivar Pnnnty Rnard of Cnunty [_nmminninnprs <br />Business Address: 1,14n 75*h Strpp$ <br />Varn Rpanh , Fi. 3796(1 <br />Phone # (400a2. -10.0P <br />Suncom #.-1444 <br />2. Certification: I, the undersigned official of the previously <br />named county, certify that to the best of my knowledge and belief <br />ell information and data contained in this EMS County Grant <br />Application and its attachments are true and correct. <br />My signature acknowledges and ensures that I have <br />read, understood, and will comply fully with <br />Appendix D of the state's EMS grant booklet titled, <br />Florida Emergency Medical Services Grant Program for <br />Counties. 1991. <br />Printed Name: Richard N. Bird Title: Chairman <br />Signature: <br />AKdad41011017 Date Signed: 9- /7-9/ <br />(Aut or zed County Official) <br />3. Authorized Contact Person: Person designated authority and <br />responsibility to provide the department with reports and <br />documentation on all activities, services, and expenditures which <br />involve this grant. <br />Name: Doug Wright <br />Title: Director, <br />Business Address: 1840 25th Street <br />Dept. of Emergency Ser <br />Vero Beach, FL 32960 <br />Telephone:(407) 567-8000 x-225 SunCom: 224-1444 <br />4. County's Federal Tax Identification Number: 59-6000674 <br />11 <br />