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f <br />+Ycr <br />APPLI 1W— N FOR <br />CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSiff'P N) <br />APPLICANT NAME: RG .Ambulance Service. Inc dba American Ambu1p10t�AlY DA'�i: 12'' #. <br />APPLICATION FEE: $100.00 APPLIES TO IN11UL A044JICATIONS ONLY* � <br />If payment applicable, make check payable to INDIAi� PJVEi%�` � 's <br />__ .. <br />0. This is a new appiII000m; fee is attached., <br />7`hid:is a renewal of:QUrpresent COLON. I. <br />0 TWO is a renewal of Out present COPCM 111 oWrAiMW or classification changes. <br />I, CLASSIFICATIOI�OF CERTIFICATEREQUESTEL <br />Please check applicable boxes and options. <br />I <br />Clare A O _BLS _ALS i <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />tmphAl EMS ALS+BLS service. - <br />Class B V VBLS ALS ., <br />Agencies that provide non-emergency*mbulance inter -facility medical transport <br />at the ALS/BLS level. <br />Class C 0 _BLS GALS <br />Agencies that provide non -emergency ambulance inter-faeilillyl medical transports <br />which require special clinal capabilities and require a physidan s order. <br />I <br />Cis D 0 _BLS ALS <br />i <br />`s <br />Agent that provide non -emergency ambulance medical transports limited to <br />out ofmunty transfers. <br />r <br />i <br />E <br />I <br />�I <br />U*WADM AMSTANTS�Beth\Beth Cauw,W=oPCMCAPCN APKICA AppRenoolfAbix I I <br />.... . .... 144. <br />i <br />f <br />