Fort Walton Beach Council agenda — 02-28-12 regular — reading text

program legislation cited above. 17. RECIPIENT SIGNATORY OFFICIAL ( Name and Title) DATE N/N/ AA N/N/ AA DATEDATE 18. FEMA SIGNATORY OFFICIAL ( Name and Title) 12-12- JANJAN - - 1212 JaneJane EarlyEarly Go Back https:// eservices. fema .govIFemaFireGrantlfiregrantlj splfire_admin /awards /speclview_awar... 2/ 21/ 2012  Page 1 of 23 Application Number: EMW- 2011 -FO -09950 ig' f' b Entire Application Overview Did you attend one of the workshops conducted by DRS' s regional fire program specialist? No, I have not attended workshop Was a workshop within 2 hours drive? Yes Are you a member, or are you currently involved In the management, of the fire department or non- affiliated EMS organization applying for this grant with this application? Yes, I am a member /officer of this applicant If you answered No, please complete the information below. If you answered Yes, please skip the Preparer Information section. m Fields marked with an are required. r7NN c Preparer information o Preparer' s Name Address 1 LL0 Address 2 mU city cn State N Q Zip Need help for ZIP +4? ry 0 In the space below please list the person your organization has selected to be the primary point of contact for this grant. This she be a Chief Officer or long time member of the organization who will see this grant through completion. Reminder: if this person changes at anytime during the period of performance please update this information. Please list only phone numbers where we c get in direct contact with you. c0 Primary Point of Contact Title Fire Chief Prefix ( check one) Mr. First Name Kenneth W E Middle Initial s U R Perkins Last Name Q Business Phone ( e. g. 123 -456 -7890) 850- 833 -9565 Ext. Home Phone ( e. g. 123 -456 -7890) 850 -585 -0350 Ext. Mobile Phone /Pager ( e. g. 123- 456 -7890) 850- 855 -1869 850- 833 -9685 Fax ( e. g. 123 -456 -7890) 1 Email ( e. g. user @xyz. org) kperkins @fwb. org Packet Pg. 49 https:// eservices. fema. gov/ FemaFireGrantlfiregrant /jsp /fire20l I / applicationlprint_app.jsp ?print=true &app_ n... 2/ 21/ 2012  2 of 23 Application Number: EMW- 2011 -FO -09950 Contact Information Alternate Contact Information Number 1 Title Battalion Chief Prefix Mr. First Name Gene Middle Initial Last Name Large Business Phone 850- 833 -9565 Ext. Home Phone 850 -200 -3175 Ext. Mobile Phone /Pager Fax Email glarge @fwb. org Alternate Contact Information Number 2 Title Captain Prefix Mr. First Name Larry Middle Initial Last Name Diamco Business Phone 850 -833 -9565 Ext. Home Phone 850 -582 -5084 Ext. Mobile Phone /Pager Fax Email Idiamco @fwb.org Packet Pg. 50 https: / c/ services. fema. gov/ FemaFireGrant /firegrant/jsp /fire20l I /application /print_app.jsp ?print= tmc &app_ n... 2/ 21/ 2012  3 Application Number EMW- 2011 -FO -09950 Applicant Information EMW- 2011 - FO -09950 Originally submitted on 09123/ 2011 by Ken Perkins ( Usend: balden) contact Information: Address: 5 NE Hollywood Blvd City: Fort Walton Beach State: Florida Zip: 32548 Day Phone: 8508339564 Evening Phone: 8505850350 Cell Phone: 8508551869 Email: kperkins @fwb. org Application number is EMW -2011 -FO -09950 Organization Name Fort Walton Beach Fire Department Type of Applicant Fire Department/ Fire District Type of Jurisdiction Served City If other, please enter the type of Jurisdiction Employer Identification Number 59- 6000323 What is your organization' s DUNS Number? 079455101 ( call 1- 866 -705 -5711 to get a DUNS number) Headquarters or Main Station Physical Address Physical Address 1 5 Hollywood Boulevard NE Physical Address 2 Fort Walton Beach City State Florida 32548- 4920 Zip Need help far ZI1`+ 41 Mailing Address Mailing Address 1 5 Hollywood Boulevard NE Mailing Address 2 Fort Walton Beach City State Florida 32548- 4920 Zip Need help for ZIP +4? 2003 AEG for purchase of SCBA Please describe all grants that you have received from DHS 2004 AEG Fire Prevention Grant " Learn not to Burn' including any AEG grant received from DHS or FEMA, for 2008 AEG for fire equipment, gear, training example, 2002 AEG grant for vehicle or 2003 ODP grant for 2009 AEG for SCBA upgrades and accountability system exercises. ( Enter ' N /A" if Not Applicable) 2010 AEG for purchase of lifepak monitor /defibrillators Account Information Type of bank account Checking Bank routing number - 960 number on the bottom left hand 063115136 corner of your check Your account number 20012993 Additional Information For this fiscal year ( Federal) is your organization receiving No Federal funding from any other grant program that may Paekel Pg. 51 https:// cservices .fema. gov /FemaFireGrant/ firegrant/jsp/ firc20 11 /application/ print_app.jsp ?print =true & app_n... 2/ 21/ 2012  Page 4 of 23 Application Number: EMW- 2011 -FO -09950 ig.t. b duplicate the purpose and /or scope of this grant request? If awarded the AM grant, will your organization expend more No than $ 500, 000 in Federal funds during your organization' s fiscal year in which this AFG grant was awarded? Is the applicant delinquent on any Federal debt? No If you answered yes to any of the additional questions above, please provide an explanation in the space provided below: c0 u