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PSM,- INDIAN RIVER COUNTY <br />�QPs•�F O <br />° DEPARTMENT OF EMERGENCY SERVICES <br />9�-N�s�P, APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />ANT;NAME: Falck Southeast II Corp d/b/a American Ambulance Service <br />March 8, 2018 <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 />® This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COCPN with ownership or classification changes. <br />CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ _BLS _ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B ® X BLS X ALS <br />Agencies that -provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ _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 ❑ Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said s�ric� <br />are paid for in part or in whole either directly or indirectly with government f�d�Q. <br />Class E1 ❑ Wheelchair Wheelchair/Stretcher Ambulatory TransR§t <br />Agencies that provide wheelchair vehicle service where said services are n„�ot pZ6 <br />for in part or in whole either directly or indirectly with government funds. r i,2rn <br />PQ -Cpm' <br />54 <br />C:\Users\jsalvesen\Desktop\Indian River COPCN 20181American Ambulance Service COPCN 2018.doc 1 <br />