HomeMy WebLinkAboutEMS Grant Fund DistributionFLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In accordance with the provisions of Section 401.113(2)(b), F. S., the um::3rsigned hereby
requests an EMS grant fund distribution for the improvement and expans.:3n or continuation of
pre -hospital EMS.
DOH Remit Payment To:
Name of Agency:
Mailing Address:
Citv of Miami Fire — Rescue
1151 NW 7 St. 3rd Floor
Miami, FLU 33136
Federal Identification Number VF 53fid00375
Authorized Agency Official:
S' nature
Robert Ruano. Grants Administrator
Type Name and Title
Sign . and return this page with your application to:
Florida Department of Health
BEMS Grant Program
4052 Bald Cypress Way, Bin C18
Tallahassee, Florida 32399-1738
Date
Do not write below this line. For use by Bureau of Emergency Medical Services personnel only
Grant Amount For State To Pay: $ 1 2'0/ o o P. 00 Grant ID Code: MS-0 4 2
Approved By: a_1-%ice5-�-.) o�
Signature of EMS Grant r D e
State Fiscal Year: �-0 C.H - D-CJc' 5
Organization Code E O OCA Object Code e_po
ettetrymmorpeelo
N7 N2000 7/ Cb00
c'1-'r3-ro-ov-Q o DSCAaq
Federal Tax ID: VFrS.Q,� 3.2 s' \rC\
Grant Beginning Date:
Grant Ending Date: ' 3(7
DH Form 1767P, Rev. June 2002
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