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ewood, Co 80235

 

 

 

Colorado Fallen Firefighter Line of Duty Death Response Team  

 

NAME:________________________________________________________________

 

ADDRESS:_____________________________________________________________

 

EMAIL:________________________________________________________________

 

PHONE: HOME_____________________________

 

CELL______________­______ WORK_____________________

 

AGENCY AFFILIATION

 

ORGANIZATION NAME:_______________________________________________

 

ORGANIZATION ADDRESS:_____________________________________________

 

RANK/POSITION:_______________________________________________________

 

YEARS OF SERVICE:___________________________________________________

 

RETIRED/ACTIVE: (CIRCLE ONE)

 

LIST AREAS OF TEAM INTEREST AND SUPPORT: (CIRCLE INTEREST/S)

 

  1. ADMINISTRATION

  2. DOCUMENTATION FOR BENEFITS

  3. CASE RESEARCH

  4. FAMILY AND AGENCY CONTACT

  5. FINANCE

  6. FUND RAISING

  7. ACCOUNT/FINANCE CONTROL

  8. COORDINATOR

  9. INCIDENT RESPONSE

  10. TEAM DOCUMENTATION

  11. TRAINING

  12. LOGISTICS – ON SITE

  13. RESOURCE ALLOCATION AND PROCUREMENT

 

PURPOSE:

 

WHAT IS YOUR PURPOSE IN VOLUNTEERING FOR THIS TEAM?

 

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

LIST THREE REFERENCES, 1 MUST BE AN OFFICER WITHIN YOUR ORGANIZATION:

 

1.______________________________________________ PHONE # ____________________________

 

2,______________________________________________ PHONE # ____________________________

 

3.______________________________________________ PHONE # ____________________________

 

 

 

ARE YOU WILLING TO TRAVEL WITHIN COLORADO FOR DEPLOYMENT WITHIN THE 6 HOUR GOAL ESTABLISHED BY THE NFFF

YES ______ NO ______

 

 WILL YOUR ORGANIZATION ALLOW YOUR RESPONSE WITHOUT REIMBURSEMENT FOR TIME AWAY FROM YOUR WORK SCHEDULE (UP TO FOUR DAYS). YES______ NO______

 

ARE YOU AWARE THAT RESPONSE ON BEHALF OF THE COFFRT IS A VOLUNTEER ACTIVITY AND THAT ONLY DOCUMENTED AND REASONABLE EXPENSES WILL BE COVERED BY THE NFFF. YES____NO_____ (Team logo shirts are not purchased by the COFFRT or the NFFF.)

 

 

 

SIGNATURE ________________________ PRINT NAME_________________________DATE______

 

 

 

Return this form to Colorado Fallen Firefighter Response Team

Colorado Fallen Firefighters Response

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