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1 <br /> GRANT APPLICATION <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Bureau of Emergency Medical Services <br /> Complete all items <br /> ID. Code he State Bureau of EMS will assign the ID Code leave this blank) <br /> 1 . County Name: Indian River County <br /> Business Address : 1800 27 Street Vero Beach Florida 32960 <br /> Telephone : 772 226-3900 <br /> Federal Tax ID Number (Nine Digit Number) . VF 59 - 60006764 <br /> 2. Certification : (The applicant signatory who has authority to sign contracts , grants , <br /> and;other Iegol 'documents for the county) I certify that all information and data in this <br /> E AIIS cW ttyj_ra' nt'application and its attachments are true and correct . My signature <br /> acknowledges and assures that the County shall comply fully with the conditions <br /> outfi6ed` in the ride WS County Grant Application . <br /> Si nature Date : <br /> Printed Name - _,, . W6sley S . Davis <br /> .Position Title: .. , ;Chairman , Board of Coun Commissioners <br /> } <br /> 3 . ContactPeftion . (The individual with direct knowledge of the project on a day-to- <br /> day basis and has responsibility for the implementation of the grant activities . This <br /> person is authorized to sign project reports and may request project changes . The <br /> signer and the contact person may be the same . ) <br /> Name : Brian S . Burkeen <br /> Position Title : Assistant Chief <br /> Address : 4225 43ru Avenue Vero Beach Florida 32966 <br /> Telephone : 772 226-3864 1 Fax Number: 772 226-3868 <br /> E-mail Address : bburkeen@ircgov. com <br /> 4. Resolution : Attach a current resolution from the Board of County Commissioners <br /> certifying the grant funds will improve and expand the county pre-hospital EMS system <br /> and will not be used to supplant current levels of county expenditures , <br /> 5. Budget: Complete a budget page (s) for each organization to which you shall provide <br /> funds . <br /> List the organization (s) below. ( Use additional pages if necessary) <br /> Indian River County Fire Rescue <br /> DH Form 1684 , Rev. June 2002 <br />