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I1. COMPANY DETAILS <br />1. NAME OF AGENCY: RG Ambulance Service, Inc. dba All County Ambulance <br />MAILING ADDRESS: 2766 NW 62nd St <br />CITY Miami COUNTY Miami -Dade <br />ZIP CODE: 33147 BUSINESS PHONE: 772-465-1111 <br />�. TYPE OF OWNERSHIP (i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />Private <br />3. MANAGER'S NAME: Jennie Petitgout <br />ADDRESS: 3326 Orange Ave, Ft Pierce, FL 34947 <br />PHONE #: 772-465-1111 <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME <br />ADDRESS <br />POSITION <br />Kay l�onzalez ztatb Nvv ozna w, Miami, rL JJ -14/ utu <br />t.j <br />Rene Gonzalez 2766 NW 62nd St, Miami, FL 33147 CFO <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />I <br />REFERENCES i..... <br />NAME ADDRESS PHONE# J: <br />Willie Bermudez 11380 SW Village Parkway Ste 100, Port St Lucie, FL 34987 (772) 301-6500 <br />David Hall 1201 SE Indian Street, Stuart, FL 34997 (772) 403-4500 _ ... <br />'I <br />John Salvesen 989 SW McDevitt Ave, Port St Lucie, FL 34953 (772) 577-1755 <br />WFIRE ADMIN ASSISTANTS\Beth\Beth Casano EOCICOPCMCOPCN APPLICATIOMCOPCN ApplicOon.docx 2. <br />153 <br />