Application Date:	Application Number:
(VDOF Headquarters Office Use Only)
PLEASE PRINT OR TYPE LEGIBILY. Complete all blanks, blank information may disqualify your application.
SECTION 1 – Company Information
Company Name:
County:	FIN Number (9-digit number):
Mailing Address:
City:	State:	Zip:
Contact Person Name:	Title:
Phone:	Email:
Size of Area Serviced:	Population:	Number of Structures:
Major Businesses and Structures Protected:
How many Wildland Urban Interface Communities are in your primary response area?
Are there specific items, which make this area hazardous for fire protection? (accessibility, values, clustering of structures, fire occurrence, etc.)
Describe Equipment (age, type, etc.):
Brush Trucks:	Year(s):
Engines:	Year(s):
Water Tenders:	Year(s):
Year(s):
Last Year Statistics:	Dispatches:	Structure Fires:	Wildland Fires:
Year Organized:	Amount of County, City or Public Funds your Company Receives Annually?:
(does not include donations from individuals)
SECTION 2 – Items Needed (in order of priority)
Item (be specific)	Wildland/Structure	Quantity	Unit Cost	Total Cost
1.	Wildland Structure	$	$
2.	Wildland Structure	$	$
3.	Wildland Structure	$	$
4.	Wildland Structure	$	$
5.	Wildland Structure	$	$
6.	Wildland Structure	$	$
Grand Total	$
SECTION 3 – Applicant Signature
Applicant Name (Print)	Applicant Signature	Date
SECTION 4 – VDOF Use Only
Score:	Approval Amount:	VDOF Approver: