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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 25th Street Vero Beach Florida 32960 <br /> Federal Identification number VF 59- 00674 <br /> Authorized Offici I : - 21 - 06 <br /> Signat <br /> - <br /> Signat Date <br /> Arthur R. Neuberger, Chairman B d 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 C18 <br /> Tallahassee, Florida 32399- 1738 <br /> Do not write below this line. For use by Bureau of Emergency 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 />