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-V ME INDIAN RIVER COUNTY <br />�QPy TF, O <br />DEPARTMENT OF EMERGENCY SERVICES <br />PSG <br />FNcY 9E APPLICATION FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) <br />APPLICANT NAME: <br />Indian River Shores Public Safety Department DATE: 2/13/2022 <br />APPLICATION FEE: $100.00 APPLI 'S 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 DOLS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B ❑ EIBLS ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ ❑BLS DALS <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 ❑ EIBLS ❑ALS <br />Agencies that provide non -emergency ambulance medical transports limited to <br />out of county transfers. <br />Class E ❑ ❑Wheelchair ❑ Wheelchair/Stretcher DAmbulatory 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 E1 ❑ IIWheelchair 1-1 Wheelchair/Stretcher DAmbulatory Transport <br />Agencies that provide wheelchair vehicle service where said services are not paid <br />for in part or in whole either directly cr indirectly with government funds. <br />