Laserfiche WebLink
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 : 1840 2e Street Vero Beach Florida 32960 <br /> Federal Identification number VF 59-6000674 <br /> Authorized Official : 5 ( t�.� 01 - 18 - 2005 <br /> Signature Date <br /> Thomas S. Lowther. Chairman Board of County Commissioners <br /> Type Name and Title <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 C 18 <br /> Tallahassee, Florida 32399. 1738 <br /> Do not write bdow this- Him For ate b Bu of Ememency Medkxl Services Demnimel 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. 0, OCA Object Codd <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 />