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1 ' 1� J ' [ <br /> 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 : Indian River County <br /> Business Address : 1800 27 Street Vero Beach Florida 32960 <br /> Telephone : 772 226 -3900 <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 thM " - MV�P - <br /> EMS y Grant Application . <br /> Sign ture : Date : January 19 , 2010 <br /> Printed Name : Peter D . O ' Br a <br /> Position Title : Chairman , Board of County Commissioners <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 : Assistant Chief <br /> Address : 422543 rAvenue Vero Beach Florida 32966 <br /> Telephone : 772 226 -3864 I Fax Number: 772 226 -3868 <br /> E - mail Address : bburkeen@ircgov . 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 county 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 Fire Rescue <br /> DH Form 1684 , Rev . June 2002 <br />