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y,INDIAN RIVER COUNTY <br />DEPARTMENT" OF EMERGENCY SERVICES <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <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 />C?,This is a renewal of our present COPCN. <br />This is a renewal of our present COPCN 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 ❑ _BLS 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 ❑ iBLS ,ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfer . <br />Class E fm Wheelchair Wheelchair/Stretcher Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said services <br />ditly or indirectly with ernment funds. <br />are paid for in pari or in whole eith�heelchair/Stretcher <br />v: <br />� <br />Class E1 wheelchair Ambulatory Transport <br />Agencies that provide wheelchair vehicle service where. said services are not paid <br />ca> <br />-� <br />for to part or In whole either directly or indirectly with government funds. <br />> uj v) <br />�1 x: <br />c <br />C-3 <br />-UJ= <br />d <br />U:\Beth\Beth Casano EOMCOPCM.RENEWAL PACKETSICOPCN Application.doc I <br />94 <br />