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Ll <br />1111111110 <br />3. Legal Status of EMS Organization (Check only one response). <br />(1) ❑ Private Not For -Profit (attach copy of IRS's 501 (c)(3) letter or other legal documentation of this status) <br />(2) ❑ Private For -Profit (3) ❑ City/Municipality <br />(4) ® County (5) ❑ State <br />4. Federal Tax ID Number: VF 5 9 6 0 0 0 6 7 4 <br />5. Medical Director <br />I hereby affirm my authority and responsibility for <br />the use of all medical equipment and continuing <br />education in this activity. <br />(7 - <br />Medical Darecto <br />1 zt Date' <br />Rnvcr 1. Nicosia. Jr. DO NOS O(l(}_s)6 --- <br />Printed Name and FL Medical License No <br />FLORIDA DEPARTMENT OF HEALTH <br />EMS MATCHING GRANT APPLICATION <br />M (BENS to. Code) <br />Total Grant Amount <br />1. BCG or EMS Organization <br />:Indian River County Board of CouBU Commissioners <br />Authorized Official <br />:Kenneth R Macht - <br />Title <br />:Chairman <br />Mailing Address <br />:1840 251h Street <br />City <br />:Vero Beach <br />State <br />:Florida <br />Zip <br />:32960 - County: Indian River <br />Telephone <br />:(5611 567-8000 ext 490 (SC): <br />Email Address <br />2. Contact Person <br />:Jim Judge <br />Title <br />:EMS Chief <br />Mailing Address <br />:1840 25i1 Street <br />City <br />:Vero Beach <br />State <br />:Florida <br />Zip <br />:32960 <br />Telephone <br />:(561) 567-2154 (SC): <br />Email Address <br />:ircesiiCa sune[ net <br />3. Legal Status of EMS Organization (Check only one response). <br />(1) ❑ Private Not For -Profit (attach copy of IRS's 501 (c)(3) letter or other legal documentation of this status) <br />(2) ❑ Private For -Profit (3) ❑ City/Municipality <br />(4) ® County (5) ❑ State <br />4. Federal Tax ID Number: VF 5 9 6 0 0 0 6 7 4 <br />5. Medical Director <br />I hereby affirm my authority and responsibility for <br />the use of all medical equipment and continuing <br />education in this activity. <br />(7 - <br />Medical Darecto <br />1 zt Date' <br />Rnvcr 1. Nicosia. Jr. DO NOS O(l(}_s)6 --- <br />Printed Name and FL Medical License No <br />