HomeMy WebLinkAboutC.054.93011_1312 (2)Iredell County Ambulance Service
Franchise Application
Type of Transport Service: ❑ Emergency ❑ Non-Emergency/Convalescent
Proposed Response Area:
Agency Name:
• Please include a brief history of applicant agency and that agency's experience in transporting
ambulance patients.
Address:
Chief Operating Officer's or Owner's Name:
Operations Manager or Chief Administrator's Name:
Contact Phone Number: Lam- Fax Number: �)-
E-Mail Address (if applicable):
1) Ability to Deliver Ambulance Services:
• Hours available for response hours per day days per week
• Estimated response time within proposed district (in minutes):
minimum:
maximum:
2) Employee and/or Member Roster:
• Include as a separate attachment a copy of the agency's employee and/or membership
roster. Include the certification levels and certification expiration dates for all personnel.
3) Vehicle Description:
• Please provide the following information for each transport ambulance:
• model year and make
• vehicle identification number (VIN)
• type category of ambulance (1, 11, 111)
• communication capabilities
• NCOEMS vehicle certification number and month of certification
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application.
4) Base of Operations:
• Please provide the location and description of the place(s) where ambulances will be
stationed.
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application.
5) State of North Carolina Ambulance Service License:
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application.
6) Agency Financial Statement:
• Please include a financial statement of the agency's revenues and expenses as it pertains to
the operations of ambulance services.
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application.
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SEP 1 9 2006 N
CJI