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APPLICATION FOR AMBULANCE FRANCHISE AND OTHER <br /> PREHOSPITAL MEDICAL SERVICE PROVIDER <br /> <br />NAME OF APPLICANT: <br />MAILING ADDRESS: <br /> <br />PHYSICAL ADDRESS: <br /> <br />OWNER (S): <br /> <br />NAME UNDER WHICH SERVICE <br />WILL OPERATE: <br /> <br />SUMMARIZE THE TRAINING <br />AND EXPERIENCE OF THIS <br />ORGANIZATION IN THE CARE <br />AND TRANSPORTATION OF <br />PATIENTS: <br /> <br />DESCRIBE THE NUMBER AND <br />TYPE VEHICLE (S) TO BE <br />OPERATED BY THE <br />APPLICANT: <br /> <br />LOCATION(S) FROM WHICH <br />AMBULANCE (S) WILL <br />OPERATE: <br /> <br />HOURS OF OPERATION: <br /> <br />DAYS OF OPERATION: <br /> <br />TYPE OF SERVICE: <br /> <br />LEVEL OF SERVICE: <br /> <br />CHARGES FOR SERVICES <br />RENDERED: <br /> <br />Cecil Dean Hastings <br /> <br />PO Box 1675 <br />Lincointon, NC 28093-1675 <br /> <br />112 S. Oak St. <br />Lincohton, NC 28092 <br /> <br />Same As Above <br /> <br />Specialized Transport <br /> <br />See Resume <br /> <br />Type II Ford Van Ambulances and <br />Ford E350 Wheelchair Vans (meets ADA Requirements) <br /> <br />Undeter~rfined location at this time <br /> <br />24 hrs. per day <br /> <br />Seven Days Per Week <br /> <br />Convalescent Only Initially <br /> <br />EMT-Basic <br /> <br />See Attachments <br /> <br /> <br />