Free 50310.pdf - Indiana

APPLICATION FOR VOLUNTEER FIRE ASSISTANCE
Department of Natural Resources \ Division of Forestry
State Form 50310 (7-01)

1. 2.

Date of Application Department Name (please provide full legal name) Department Address

3.

4. 5.

Was this department formed within the last 24 months? Department NIFRS Number

Yes \ No

(2 digit county + 3 digit department, example 55.015) Township

6. 7. 8. 9. 10. 11. 11.

County

Federal Tax Identification Number _____ - _____________________ (9 digit number) What is the approximate population base served by your department? What is the approximate size of your departments primary protection area? (square miles) Attach a county or township map showing the location of your department and the primary protection area for which you are responsible to the back of the application. What is the current Insurance Services Office (ISO) rating for your protection area? ______________________ List any federal or state (public) properties (greater than 500 acres) that fall within your primary protection area.

(property name) continue on next page

(Total Acreage)

12.

Is this request for assistance based on an emergency situation that jeopardizes your ability to provide fire protection to your protection area? Yes \ No If "Yes" please explain in the space below. You may attach additional sheets if necessary.

13.

Is this request for assistance a "multi-department" or "multi-community" proposal? If "Yes" please explain in the space provided below. You may attach additional sheets if necessary.

Yes \ No

14.

The applicants certify that to the best of their knowledge that the information provided in this application to be true and correct, and that they will comply with the program guidelines if accepted. (Please print or type the applicant's full name (Signature) (Business Telephone Area Code + Number + Extension) Telephone Area Code + Number) Return this application to: Fire Control Headquarters 6220 Forest Road Martinsville, IN 46151 Phone (765) 342-4701 Fax (765) 342-4760 (Official Title) (Date) (Home