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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: Senior Resource ASSOCiatiCn, inC. DATE: 8/18/2021 <br />APPLICATION FEE: $100.00 APPLIES TO INITIAL APPLICATIONS ONLY. <br />It 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 COPCN with ownership or classification changes. <br />CLASSIFICATION OF CERTIFICATE REQUESTED <br />Please check applicable boxes and options. <br />Class A ❑ ❑BLS [7]ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B ❑ LBLS ❑ALS <br />Agencies that provide non -emergency ambulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C ❑ ❑BLS QALS <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 L Wheelchair/Stretcher V/Ambulatory Transport <br />Agencies that provide wheelchair transportation service only where said services <br />are paid for in part or in whole eitner directly or indirectly with government funds. <br />Class E1 ❑ Ilwheelchair L Wheelchair/Stretcher FAmbulatory 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:1Beth\Beth Casano EOMCOPCMRENEWAL PACKETS�COPCN Applicatlon.doc <br />35 <br />