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EMS COUNTY GRANT APPLICATION <br /> FLORIDA DEPARTMENT OF HEALTH <br /> Bureau of Emergency Medical Services <br /> Complete all items <br /> ID Code (The State Bureau of EMS will assign the ID Code — leave this blank) C <br /> 1 . County Name: <br /> Business Address: <br /> Telephone: (000) 123-4967 <br /> Federal Tax ID Number Nine Digit Number). VF 123-45-6789 <br /> 2. Certification : (The applicant signatory who has authority to sign contracts, grants, and other legal <br /> documents for the county) I certify that all information and data in this EMS county grant application and <br /> its attachments are true and correct. My signature acknowledges and assures that the County shall <br /> comply fully with the conditions outlined in the Florida EMS County Grant Application. <br /> Signature: Date: <br /> Printed Name: <br /> Position Title: <br /> 3. Contact Person : (The individual with direct knowledge of the project on a day-to-day basis and has <br /> responsibility for the implementation of the grant activities. This person is authorized to sign project <br /> reports and may request project changes. The signer and the contact person may be the same.) <br /> Name: <br /> Position Title: <br /> Address: <br /> Tele hone: (000) 000-0000 Fax Number: (000) 000-0000 <br /> E-mail Address: abcdefg@zyx.wm <br /> 4. Resolution: Attach a current resolution from the Board of County Commissioners certifying the grant <br /> funds will improve and expand the county pre-hospital EMS system and will not be used to supplant <br /> current levels of county expenditures. <br /> 5. Budget: Complete a budget page(s) for each organization to which you shall provide funds. <br /> List the organization(s) below. (Use additional pages if necessary) <br /> DH Form 1684, Rev. June 2002 <br /> 3 <br />