Volunteer Fire Department Grant Application *Fire Department Name: *P.O. Box/Street Address: *City: *State: *Zip Code: *Contact Person: *Title: Contact Phone Numbers: *Daytime Phone Number: Nighttime Phone Number: *Email Address: *Annual Operating Costs of VFD: If applicable, for the most recent previously submitted application, list the date of the application and the amount awarded. Date Last Application Submitted: (MM/DD/YYYY) Amount Awarded: Grant Request Information *Amount Requested: *VFD Insurance Rating: *Purpose of request. Include specifics on how funds will be used and list itemized costs of all equipment needed: *How is your VFD Funded?: *Other sources of assistance that have been applied for and/or received. Please list source and dollar amount for each: *Community Support: Equipment Fire Department Owns (check each item) Class "A" Pumper with 500 gpm Pump: 750 Gallon Water Tank (or larger): Four Self-contained Breathing Apparatus: One Spare SCBA Bottle for Each Above: One Personal Alert Safety Device: 800' - 2 1/2" Hose - Supply Line: 400' - 2 1/2" Hose - Atack Line: (2) 200' - 1 1/2" Hose Lines: (2) 10' x 5" Hard Suction Hose: (1) 5" Hose Strainer : (2) 2 1/2" Adjustable Nozzles: (2) 1 1/2" Adjustable Nozzles: (1) Bresnan Nozzle or Piercing Nozzle: (1) Master Stream Device(with accessories): (1) Hydrant Gate Valve, Hose Clamp, Jacket) : (2) Sets Hose/Hydrant Wrenches: (2) 20 BC Fire Extinguishers (ABC)(Co2): (1) 24' Extension Ladder: (1) 12'-14' Roof Ladder: (1) 8' - 10' Attic Ladder: (1) Crow Bar: (1) Pry Bar - 48" - 60": (1) Pick Head Axe: (1) Flat Head Axe: (1) Halogen Tool: (1) Tool Box (Assorted Hand Tools): (2) Portable Hand Lights: (2) Portable Scene Lights: 59' - 100' Extension Cord: (1) Truck Mounted Radio Fire/Emer. Channels: (1) Hand Held Radio with Above Frequencies: (1) 5000 Watt Generator: (1) Positive Pressure Fan: (1) OSHA/NFPA Approved First-Aid Kit: (1) Hose Bed Cover: (1) Set Wheel Chocks: Per Person: Helmet with Nomex Guard W/Accessories: Nomex Hood: Coat with Vapor Barrier: Pants with Vapor Barrier: Suspenders: Boots: Gloves: Other Equipment Not Listed: Other Equipment 1: Other Equipment 2: Other Equipment 3: Other Equipment 4: Other Equipment 5: Effectiveness *How are programs measured for effectiveness?: Community Impact Number of individuals, families, or groups served in Bryan, Liberty, Long, McIntosh counties: *Number Served in Listed Counties: Number Served Outside of Listed Counties: Counties Where Other Recipients Reside: Financial Condition Is the fire department exempt from the payment of income tax? *Tax Exempt?: Yes No If "Yes", upload a copy of the exemption letter from the IRS (Form 501(c)(3)) below. Upload Copy of Form 501(c)(3): Upload copies of most recent financial statements. For multiple documents, hold down the Ctrl key while clicking on document name. *Financial Statements: References *List the Name, Address, and Phone number for three (3) references: The information contained in this statement is for the purpose of obtaining funding from the Coastal EMC Foundation, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used in deciding to grant funding, and each undersigned represents and warrants that the information provided is true and complete and that The Coastal EMC Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of change is provided. The Coastal EMC Foundation, Inc. is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Fire Department Name: Click here to draw your signature. Authorized Signature With your mouse, draw your signature. Then click Finish. Date:(MM/DD/YYYY)
