Florida Department of Agriculture and Consumer Services Florida Forest Service

FREE FIRE PREVENTION MATERIALS HURRICANE VFA GRANT APPLICATION

LEGAL NAME

ADDRESS

FORM OF ORGANIZATION: (Municipal, Fire District, Non-Profit, County)

CITY

STATE ZIP

COUNTY COUNTY #

EMPLOYER IDENTIFICATION NUMBER (EIN)

-

IF COUNTY, LIST VFD’S BENEFITING FROM GRANT:

IS FIRE DEPARTMENT LOCATED IN AN INCORPORATED TOWN? WHAT IS THE FIRE DEPARTMENT ISO RATING?

YES NO IF YES, NAME OF TOWN: CURRENT COOPERATIVE AGREEMENT WITH DOF? YES NO

POPULATION OF TOWN: DISTANCE OF CLOSEST MUTUAL AID FIRE DEPARTMENT:

PROTECTED AREA: EST. POPULATION: SIZE: (SQ. MILES) NAME OF FIRE DEPARTMENT:

NUMBER OF PAID FIREFIGHTERS: PAID: VOLUNTEERS: HAS APPLICANT RECEIVED GRANT FUNDS FROM ANY SOURCE IN THE PAST 12 MONTHS? YES NO

NO. OF INCIDENTS PAST YEAR: WILDLAND FIRE: OTHER: IF YES, WHERE?

NO. OF FIREFIGHTERS CERTIFIED AS: WILDLAND FIREFIGHTER I WILDLAND FIREFIGHTER II

AMOUNT: $

NO. OF STORMS/HURRICANES AFFECTING AREA IN 2004 WITH SUSTAINED WINDS ABOVE 40 MPH:

LIST TOTAL FUNDS RECEIVED FROM OTHER TAXING AUTHORITIES SUCH AS CITY, COUNTY, TAXING DISTRICTS (Past 12 Months) AMOUNT: $

NICOLE "NIKKI" FRIED COMMISSIONER

Please attach a vendor order form for the prevention materials to be ordered. Include the shipping address, contact, and phone number for the delivery.

Orders should not be in excess of $3,000.

We understand that this is a FREE PROGRAM (Cooperative Forestry Assistance Act of 1978, PL 95-313). TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION ARE TRUE AND CORRECT. THE GOVERNING BODY OF THE APPLICANT HAS DULY AUTHORIZED THIS DOCUMENT.

Type Name of Authorized Representative Title Telephone Number: ( )

FAX: ( )

Signature of Authorized Representative Date Signed and Submitted Email:

FDACS-11483 Rev. 02/11