ATTESTATION: In signing this application, we are attesting that all information contained herein is accurate and that we and our attesting hospital agrees to be bound by the rules, policies and decisions of the Indiana Emergency Medical Services Commission and the Indiana State Department of Health regarding our status under this program. Chief Executive Officer Signature Printed Date Trauma Medical Director Signature Printed Date Trauma Program Manager Signature Printed Date 01/22/2014
ATTESTATION: In signing this application, we are attesting that all information contained herein is accurate and that we and our attesting hospital agrees to be bound by the rules, policies and decisions of the Indiana Emergency Medical Services Commission and the Indiana State Department of Health regarding our status under this program. Chief Executive Officer Signature Printed Date Trauma Medical Director Signature Printed Date Trauma Program Manager Signature Printed Date 01/22/2014