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INDIAN RIVER COUNTY <br />DEPARTMENT OF EMERGENCY SERVICES <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME:ift 111-c of i)t Cot) <br />A ci DATE: b' I Z.s'i? <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCUE. <br />❑ This is a new application; fee is attached. <br />f 'This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COPCN with ownership or classification changes. <br />I. CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A 0 _BLS _ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />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 0 _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 Lel 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 El 0 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 />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />l <br />P61 <br />