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l r ++ <br /> DEPARTMENT OF HEALTH <br /> EMS GRANT PROGRAM <br /> REQUEST FOR GRANT FUND DISTRIBUTION <br /> In accordance with the provisions of Section 401 . 113 (2) (a) , F. S . , the undersigned <br /> hereby requests an EMS grant fund distribution for the improvement and expansion of <br /> pre-hospital EMS . <br /> DOH Remit Payment To : <br /> Name of Agency : Indian River County Board of County Commissioners <br /> Mailing Address : 1800 2r Street Vero Beach Florida 32960 <br /> Federal Identification number VF 59-6000674 ti <br /> Authorized Official :f,4: � r 79, 2 <br /> Signature Date <br /> Wesley S. Davis. Chairman Board of County rd1mauissil6kers <br /> Type Name and Title <br /> 10 <br /> Sign and return this page with your application to: <br /> Florida Department of Health <br /> BEMS Grant Program <br /> 4052 Bald Cypress Way, Bin C18 <br /> Tallahassee, Florida 32399- 1738 <br /> Do not write below this line. For use by Bureau of Emereencv Medical Services personnel only <br /> Grant Amount For State To Pay: $ Grant ID: Code: <br /> Approved By : <br /> Signature of EMS Grant Officer Date <br /> State Fiscal Year: - <br /> Organization Code E . O . OCA Object Code <br /> 64-25-60-00-000 N N2000 7 <br /> Federal Tax ID : VF <br /> Grant Beginning Date: October 1 , Grant Ending Date : September 30 , <br /> DH Form 1767P , Rev. June 2002 <br />