HomeMy WebLinkAboutRequest for 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 undersigned hereby requests an
EMS grant fund distribution for the improvement and expansion or continuation of pre -hospital EMS.
DOH Remit Payment To:
Name of Agency: City of Miami Fire — Rescue
Mailing Address: 1151 NW 7 St. 3rd Floor
Miami, FL 33136
Federal Identification Number F 596 1 i ! 375
Authorized Agency Official:
1/0
ignature r ate
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
Do not write below this line. For use by Bureau of Emergency Medical Services
personnel only
Grant Amount For State To Pay: $ Grant ID Code:
Approved By:
Signature of EMS Grant Officer Date
State Fiscal Year:
Organization Code E.O. OCA Object Code
64-25-60-00-000 N N2000 7
Federal Tax ID: VF
Grant Beginning Date: Grant Ending Date:
DH Form 1767P, Rev. June 2002