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9/30/2015 7:40:38 PM
Official Document Type
Agenda Item Number
Bureau of Emergency Medical Services
Grant Application FY 2004-2005 EMS County Awards Grant
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GRANT APPLICATION <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Bureau of Emergency Medical Services <br /> Com lett all items <br /> M The State Bureau of EMS will assign the ID Code - leave this blank C <br /> 1 . County Name: Indian River County <br /> Business Address: 1840 25m Street Vero Beach Florida 32960 <br /> Telephone : 772 5674154 <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 legal documents for the county) I certify that all information and data in this <br /> EMS county grant application and its attachments are true and correct. My signature <br /> acknowledges and assures that the County shall comply fully with the conditions <br /> outlined in t Flo ' a EMS County Grant Application . <br /> t <br /> Signature : Date : January 18 , 2005 <br /> Printed Name : Thomas S. Lowther <br /> Position Title: Chairman, Board of CountCommissioners <br /> 3. Contact Person : (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: EMS Chief <br /> Address: 1840 2V Street Vero Beach Florida 32960 <br /> Tele hone: 772 5624028 X 3015 Fax Number: 772 770=5147 <br /> E-mail Address : email@example.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 count 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 Department of Emergency Services <br /> DH Form 1684, Rev, June 2002 <br />
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