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iMF,y, INDIAN RIVER COUNTY <br />DEPARTMENT OF EMERGENCY SERVICES <br />o m o <br />Z.. <br />APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />Indian River County Department of Emergency Services DATE: 09/� 0/2020 <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />If payment applicable, make check payable to INDIAN RIVER COUNTY FIRE RESCU <br />❑ This is a new application; fee is attached. <br />® This is a renewal of our present COPCN. <br />❑ This is a renewal of our present COPCN with ownership or classification chan <br />I. CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ ❑BLS [Z]ALS <br />Governmental entities that use advanced life support vehicles to conduct a <br />hospital EMS ALS/BLS service. <br />Class B ❑ LIBLS []ALS <br />Agencies that provide non -emergency ambulance inter -facility medical trans <br />at the ALS/BLS level. <br />Class C ❑ []BLS ❑ALS <br />Agencies that provide non -emergency ambulance inter -facility medical trans <br />which require special clinical capabilities and require a physician's order. <br />Class D ❑ ❑BLS []ALS <br />Agencies that provide non -emergency ambulance medical transports limited <br />out of county transfers. <br />Class E ❑ O—wheelchair 1:1 Wheelchair/Stretcher IIAmbulatoryTransr <br />Agencies that provide wheelchair transportation service only where said sery <br />are paid for in part or in whole either directly or indirectly with government fun <br />Class E1 ❑ IIWheelchair n Wheelchair/Stretcher IIAmbulatory Transport <br />Agencies that provide wheelchair vehicle service where said services are not <br />for in part or in whole either directly or indirectly with government funds. <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc I%$ <br />