HomeMy WebLinkAboutC.054.93011_1313 (2)SEP 9 9 2006
7) Proof of Vehicle & Liability Insurance:
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application.
8) Declaration/Declination of Ambulance Service Fees:
• Include as a separate attachment with the Iredell County Ambulance Service Franchise
Application (see enclosed Iredell County Billing Declaration/Declination Form).
Attachments Checklist:
New Applicants:
O Applicant Agency History & Experience
O Base of Operations
O Employee/Membership Roster
O NC Ambulance License
O Vehicle Description(s)
O Financial Statement
O Proof of Vehicle & Liability Insurance
O Declaration/Declination of Ambulance Service Fees
Renewal Applicants:
O Employee/Membership Roster
O Financial Statement
O Proof of Vehicle & Liability Insurance
O Declaration/Declination of Ambulance Service Fees
Note: Agencies renewing an existing franchise agreement need only submit the items listed above
along with the Iredell County Ambulance Franchise Application. Information concerning Agency
History/Experience, Base of Operations, NC Ambulance License, and Vehicle Description(s) should be
re -submitted annually if changes occur in any of those items.
Chief Operating Officer's/ Owner's Signature &Title Date of
Application
* Renewal Applicant's Note: Signature above indicates that no changes have
occurred in Agency History/Experience, Base of Operations, NC Ambulance
Return completed franchise applications to:
Joel Mashburn, County Manager
Iredell County Government Center
200 S. Center St.
P.O. Box 788
Statesville, NC 28687-0788
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