NCAFC WS Application Form

County Association/Department Name

Region

West

Piedmont

East

Number of departments in county association

Number of stations in department participating in the grant:

List participating department(s) and chiefs (under this county association).

Type of association/organization

Volunteer

Combination

List

# of Volunteers

# of Auxiliary

# of Career

# of Fire Stations

# of Administrative Staff

Population Serviced

Square Miles Served

Website

Facebook Page

Contact Name

Title

Contact Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell Phone

Fax

Direct Email

Are you willing to brief your Board Chair/County Mayor/administrator about the program?

Yes

No

Board Chair/County Mayor/Administrator Name (City/Town)

Title

Contact Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell

Fax

Direct Email

How will this program assist in your department's need to adequately comply with NFPA 1710 or NFPA 1720?

Describe your need for this program and how it will benefit your department.

Do you have a formal or informal recruitment and retention program? If so, please explain.

Do you have a designated volunteer coordinator/recruiter?

Yes

No

How do you track potential new members and where they currently are in the new member process (medical completed, application, background check, etc.)?

How will you ensure that recruitment and retention data is submitted to workforce solution staff on a monthly basis?

Will all of your participating county group departments be willing to commit to the requirements as stated in the Memorandum of Understanding?

Yes

No

MOU attached for view only, no signature required at this moment.

Are you a north Carolina Association of Fire Chiefs member? (This is not a requirement).

Yes

No

Who is your contact for membership?

Do you currently have a FEMA SAFER award for recruitment and retention?

Yes

No

What does the reward entail?

Additional Comments (optional)

MOU

LINK TO MOU

NCAF Application Form

MOU