Hertford County, NC

The name and address of the ambulance provider and of the owner of the ambulance (s).*

The trade or other fictitious names, if any, under which the applicant does business, along with a certified copy of an assumed name certificate stating such name or articles of incorporation stating such name.*

A resume of the training and experience of the applicant in the transportation and care of patients.*

A full description of the type and level of service to be provided including the location of the place or places from which it is intended to operate, the manner in which the public will be able to obtain assistance and how the vehicles will be dispatched.*

An annual audited financial statement of the applicant as the same pertains to the operation in the County of Hertford shall be filed with the County of Hertford shall be filed with the County of Hertford within 60 days following its fiscal period, said financial statement to be in such form and in such detail as may be required by the County.*

A description of the applicant’s capability to provide service: how many hours a day the service will be available: how many days a week the service will be available for the district covered by the franchise applied for and an estimate of the minimum and maximum times for a response to calls within such district.*

If applicant desires to provide service to only a portion of Hertford County, applicant shall attach a map or other description of proposed service area; otherwise, this shall be an application for Countywide Service.*

Type of Franchise:*

Basic life support: Non-emergency Transport

Basic life support: Emergency

Advanced life support: Non-emergency Transport

Advanced life support: Emergency

Describe how: The proposed service will fit within the existing service so as not to adversely affect the level of service or operations of other franchisees or render service.*

Describe why: A need exists for the proposed service in order to improve the level of ambulance services available to residents of the county and that this is a reasonable cost-effective manner of meeting the need.*

Standards for Drivers and Attendants*

Standards for Vehicles and Equipment (List vehicles and Level of care)*

Standards for Communication (List equipment for each vehicle)*

Insurance Carrier and Proof (As required by Section IX)*

Rates and Charges*

Request: Todays Date*

Signature*

Agency*

Position*

Hertford County Ambulance Franchise application form