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APPLICANT NAME: RG Ambulance Service, Inc. dba All County Ambulance DATE12/52024 <br />APPLICATION FEE: $100.00 APPLIESTO 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 COPCN with ownership or classification changes. <br />I. CLASSIFICATION OF CERTIFICATE REQUESTED I <br />Please check applicable boxes and options. <br />Class A ❑ _BLS _ALS <br />Governmental entities that use advanced life support vehicles to conduct a pre- <br />hospital EMS ALS/BLS service. <br />Class B S� V BLS VALS I. ._. <br />Agencies that provide non-emergency ambulance inter-facility medical transport s <br />at the ALS/BLS level. <br />Class C ❑ _BLS _ALS <br />Agencies that provide non-emergency ambulance inter-facility medical transports t <br />which require special clinical capabilities and require a physician's order. <br />Class D ❑ BLS ALS I <br />- - i <br />Agencies that provide non-emergency ambulance medical transports limited to <br />Out of county transfers. <br />i <br />WFIRE ADMIN ASSISTANTS\Beth\Beth Casano EOCICOPCN\COPCN APPLICATIONICOPCN Application. docx l <br />.152 <br />4 <br />