Apply for an EMS Equipment Grant | Seattle, WA

I. Agency Contact

Applicant Agency:

Contact Person: *

Title:

Address

Street Address City State ZIP Code

Phone: *

Fax:

Email: *

II. Funding Request

Funding will be on a matching basis. The Medic One Foundation may contribute up to 75% of the cost of the requested equipment.

(Please list only the total amount of requested funds by category on this page. If you are requesting a grant for more than one item, please include an itemized list of your funding request in section IV. Requests for equipment costing $1,000 or more must include two vendor bids verifying the cost.)

Medical Equipment:

Medical Equipment - Amount Requested:

Amount Requested

Medical Equipment - Matching Funds from Agency:

Matching Funds from Agency

Medical Equipment - Total Cost:

Total Cost

Other:

Other - Amount Requested:

Amount Requested

Other - Matching Funds from Agency:

Matching Funds from Agency

Other - Total Cost:

Total Cost

Total:

TOTAL - Amount Requested:

Amount Requested

TOTAL - Matching Funds from Agency:

Matching Funds from Agency

TOTAL - Total Cost:

Total Cost

Equipment Item Requested:

Describe the need and how the funds will enhance the delivery of emergency medical services.

Why is this funding needed at this time? What will happen if you do not receive the funding?

Why are you not including this purchase within your regular operations or capital budget?

If your request is funded, how will you acknowledge or recognize the Medic One Foundation?

Please indicate the total dollar amount of charitable gifts your agency received in the last fiscal or calendar year.

III. Agency Information

Name and number of Fire Protection District/Department:

Name of Chief:

Mailing Address:

Phone:

Fax:

Email:

AGENCY RESPONSE INFORMATION

For most recent year of:

Total # of responses:

Total # of EMS responses:

Percent EMS aid responses:

Number of ALS responding units:

Number of BLS responding units:

DEMOGRAPHIC INFORMATION

Square miles in service area:

Population served:

Special areas or miles in service area:

PERSONNEL

Number of full-time personnel:

EMTs:

Paramedics:

Number of volunteers:

Number of volunteers EMTs:

IV. Budget

Please identify the source of matching funds.

EMS Budget for current year of:

Dollar Amount:

Do you have a depreciation funding plan for the requested equipment?:

Yes
No

Total Fire Department Operating Budget:

If you are requesting a grant for more than one item, please provide a detailed listing of your funding request, along with individual costs:

For items costing $1,000 or more, please upload vendor bid(s) here: BID ONE

Accepted file types: doc, pdf, txt, gif, jpg, jpeg, png, Max. file size: 21 MB.

Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.

For items costing $1,000 or more, please upload vendor bid(s) here: BID TWO

Accepted file types: doc, pdf, txt, gif, jpg, jpeg, png, Max. file size: 21 MB.

Acceptable file types: doc,pdf,txt,gif,jpg,jpeg,png.

EMS Equipment Grant Application

I. Agency Contact

II. Funding Request

III. Agency Information

IV. Budget

Your gift will be matched dollar for dollar!

Your gift will be matched
dollar for dollar!