County/Operational Area:
{var OPerationalArea}
|
Requesting Jurisdiction Name:
{var ReqJuridiciton} |
24 Hour Phone Number:
{var phone24} |
OA EMMA Coordinator / PRIMARY Point of Contact Name:
{var coordinatePOC}
|
Phone:
{var coordPhone}
|
Alternate Phone:
{var coordaltphone} |
FAX
{var coordFax}
|
E-Mail:
{var PocEamil}
|
Providing Jurisdiction Point of Contact:
{var altPOC}
|
Position / Title:
{var AltTile}
|
Phone:
{var AltPOCphone}
|
Alternate Phone:
{var altPOCAltPhone}
|
FAX:
{var altPOCfax}
|
Email :
{var altPOCEmail}
|
Providing Jurisdiction Authorization: (The following signature of the Providing Jurisdiction indicates a good-faith effort to ensure the EMMA resource(s) listed on this form is qualified to fulfill the request and is available for deployment. It is understood that this form does not constitute a contract with the Requesting Jurisdiction. Mutual aid extended under the EMMA Plan shall be without reimbursement unless otherwise established in a separate pre/post-event agreement between the Requesting and Providing Jurisdictions.)
Print Name and Title:
{var JAName} Signature:
{var JASig}
|
|
CONTINUED - POTENTIAL EMMA RESOURCE INFORMATION (MAY LIST UP TO 4 PEOPLE PER POSITION): |
#1
{var person1checked1}
(For Requesting Jurisdiction only: Check this box to select EMMA resource for assignment.) |
Name:
{var personName1} |
Title:
{var PersonTitle1} |
Cell Phone:
{var PersonCell1} |
Email:
{var PersonEmail1} |
Available for time as specified on Form A?
{var availableValue1}
|
Able to perform tasks described in Form A?
{var AbleValue1} |
Security Clearance (If applicable)?
{var securityval1} |
Has required equipment per Form A?
{var hasEqpval}
(Personal Equipment Disclaimer HERE)
|
Is aware of expected working conditions? {var WorkAwareVal1} |
Self-Contained?
{var selfContain1val1}
|
Comments/Other:
{var specExplain1} |
Experience / EOC Position Credentials:
{var Experience1}
|
Special Skills / Licenses / Certifications:
{var specialSkill1}
|
Originating City/County:
{var OriginatingCounty1} |
Estimated Travel Time::
{var TravelTime1} |
Emergency Contact Name:
{var Emergontact1}
|
Relationship::
{var contactRelation1} |
Cell Phone:
{var EmgContCell1} |
Email:
{var EmgContEmail1} |
Special Pay/Compensation Considerations:
{var specialPay1}
|
|