HomeMy WebLinkAboutEMS Grant Fund Distribution 2FLORIDA DEPARTMENT OF HEALTH
EMS GRANT PROGRAM
REQUEST FOR GRANT FUND DISTRIBUTION
In acc dance with the provisions of Section 401.113(2)(b), F. S., the undersigned hereby requests ail
EMS g ant fund distribution for the improvement and expansion or ^ontinuation of pre -hospital EMS.
DOH Remit Payment To:
Name of Agency: _ City of Miami Fire — Rescue
Mailing Address:
Federal Identification Number
1151 NW 7 St. 3rd Floor
Miami, FL 33136
7.//49
ate
Authorized Agency Official:
1
Robert Ruano, Grants Administrator
Type Name and Title
nature
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
os
Do not write below this line. For use by Bureau of Emergency Medical Services
personnel only
Grant Amount For State To Pay: $
CJ
DD Grant ID Code: /vl-a 9 /
Approved By: / .5 a
Signature of EMS Grant 0 icer Date
_VaL
State Fiscal Year: t-( - 01.Co 5-
Oriz ganation Dodd 0. OCA Object Code
6* 25 0-00-000 N2000 71000 C)
CSC(-YZ •/0-oa-� r7.-
Federal Tax ID: VFS1/_ a Y ?S '-' \2Ck
Grant Beginning Date: 7'../Grant Ending Date: Vi30 /p
of C.
DH Form 1767P, Rev. June 2002