About The Program
Apply for a Grant
Contact Us
Thank You
To be filled out by Department
DEPARTMENT INFORMATION
*
Indicates required field
Name of agency or department
*
Volunteer Department?
*
Yes
No
Contact name
*
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
County
*
Please attach a copy of your agency’s (or department’s) W9 for accounting purposes.
In the event your department is not selected for a grant, the W9 will be destroyed.
Please attach a copy of a map showing department response zone.
501(c)(3) STAT
US - These questions are for internal us
e only, and will not affect your eligibility for a grant.
Department Type
*
Government Entity
Non-Government Entity
If non-government, has your department applied for 501(c) (3) status? If yes please attach a copy of your current 501(c)(3) letter.
*
Yes
No
Not Applicable
ADDITIONAL INFORMATION
1. Likelihood to respond to an FHR emergency.
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High
Medium
Low
Total annual budget
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Population site serviced
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Total number of personnel
*
Percentage of perso
nnel paid vs. volunteer
Paid
*
Enter 0% if none.
Volunteer
*
Enter 0% if none.
Please let us know what type of equipment your department or organization has and its age:
*
DESCRIPTION O
F NEED (
Not more than 300 words - attach sheets as needed)
What materials / services are needed and why?
*
Try to be specific as possible.
How will the grant increase the unit's ability to serve the community and/or protect your personnel?
*
Estimated cost to meet need (itemize if appropriate)
*
Itemize if appropriate.
COMMUNITY INVOLVEMENT (Not more than 100 words - attach sheets as needed)
How long has the department been in operation?
*
About how many people/households does it serve?
*
Services performed.
*
What percentage of your call volume is fire related, and what percentage is EMS related?
Fire
*
Enter 0% if none.
EMS
*
Enter 0% if none.
SPECIAL CONSIDERATIONS
Other information that will add to the understanding of the department's needs.
*
Not more than 100 words-attach additional Information, if necessary or desired.
Submit
