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3 APPLICATION (Requires Signature) <br /> REQUEST FOR COUNTY GRANT DISTRIBUTION (ADVANCE PAYMENT) <br /> EMERGENCY MEDICAL SERVICES (EMS) <br /> COUNTY GRANT PROGRAM <br /> In accordance with the provisions of section 401.112(2)(a), F.S., the undersigned hereby <br /> requests an EMS county grant distribution (advance payment) for the improvement and <br /> expansion of prehospital EMS. <br /> Payment To: Indian River County Board of County Commissioners <br /> Name of Board of County Commissioners (Payee) <br /> Federal Tax ID Number of County: VF596000674 <br /> Authorizing County Official <br /> SIGNATURE: Date: 01-21 -2003 <br /> Printed Name: Kenneth'Macht Title: Chairman,Board of County Commissioners <br /> SIGN AND RETURN WITH YOUR GRANT APPLICATION TO: <br /> Department of Health <br /> Bureau of Emergency Medical Services <br /> EMS County Grants <br /> 2002D Old St. Augustine Road <br /> Tallahassee, Florida 32301-4881 <br /> For Use Only by Department of Health <br /> Bureau of Emergency Medical Services <br /> Amount: $ Grant Number: <br /> Approved By: Date: <br /> Signature, State EMS Grant Officer <br /> Fiscal Year: Amount:$ <br /> Or anization Code E.O. Object Cod64-25-60-00-000 e <br /> Federal Tax I.D. VF <br /> Beginning Date: Ending Date: <br />