Emergency Assistance Request Form

Cooperative Requiring Assistance*

Primary Contact's Name*

First Last

Primary Contact's Phone Number*

Primary Contact's Email*

Secondary Contact Name(s) and Phone Numbers

When entering multiple secondary contacts, please use the following format: Name (123)456-7890; Name (123)456-7890.

Nature of Disaster*

Estimate Number of Members Affected*

Estimate of Line Damage and Percentage of Miles*

Weather and Road Conditions*

Where and to Whom Should Crews Report?*

Please include the location, name, and phone number using the following format: Location, Name (123)456-789.

Estimation of Length of Time Outside Crews Are Needed*

Requests for Trucks

Type of Truck and Quantity Requested

Please use the following format: Truck Type (Quantity); Truck Type (Quantity); etc.

Notes

Type of Equipment/Tool and Quantity Requested

Please use the following format: Tool/Equipment (Quantity); Tool/Equipment (Quantity); etc.

Notes

Personnel Classification and Quantity Requested

Please use the following format: Personnel Classification (Quantity); Personnel Classification (Quantity); etc.

Notes

Materials and Quantity Requested

Please use the following format: Material (Quantity); Material (Quantity); etc.

Notes