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C) q-061 <br />City :Vero Beach <br />State :Florida <br />Zip :32960 <br />Telephone (5611 567-2154 (SC): <br />Email Address :irces'psuner net <br />3. Legal Status of EMS Organization (Check only one response). <br />('I) ❑ 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 596000674 <br />5. Medical Director <br />t hereby affirm my authority and responsibility for <br />the use of all medical equipment and continuing <br />education in this activity. <br />MediDid (ctor <br />Roger J Nicosia, Jr. D0__LnS ))5396 Date: <br />Printed Name and FL Medical License No. <br />FLORIDA DEPARTMENT OF HEALTH <br />EMS MATCHING GRANT APPLICATION <br />yI (BEMS ID. Code) <br />Total Grant Amount <br />1. BCC or EMS Organization <br />:Indian River ount�Board of County (bmmissioners <br />Authorized Official <br />:Kenneth R. Macht <br />Title <br />:Chairman <br />Mailing Address <br />:1840 25i1 Street - <br />City <br />:Vero Beach <br />State <br />:Florida <br />Zip <br />:32960 County: Indian River <br />Telephone <br />:(561) 567-8000 ext 490 (Sc): <br />Email Address <br />2. Contact Person <br />:Jim Judge <br />Title <br />:GMS Chief <br />Mailing Address <br />:1840 25i1 Street <br />City :Vero Beach <br />State :Florida <br />Zip :32960 <br />Telephone (5611 567-2154 (SC): <br />Email Address :irces'psuner net <br />3. Legal Status of EMS Organization (Check only one response). <br />('I) ❑ 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 596000674 <br />5. Medical Director <br />t hereby affirm my authority and responsibility for <br />the use of all medical equipment and continuing <br />education in this activity. <br />MediDid (ctor <br />Roger J Nicosia, Jr. D0__LnS ))5396 Date: <br />Printed Name and FL Medical License No. <br />