Download Lamoille Cty SD appl..

National Resource Typing
By signing (or typing if submitting electronically) below I confirm that this agency will complete the National Resource Typing
Survey(s) distributed by the Vermont Homeland Security Unit. This agency understands that if this application is approved
and an award issued, it also accepts the responsibility for completing additional NIMS surveys as requested by the Vermont
Homeland Security Unit.
Applicant Signature
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Printed Name
Title
Date
Roger M. Marcoux Jr.
Sheriff
3-Mar-II
Fire Service only: National Fire Incident Reporting System (NFIRS)
By signing (or typing if submitting electronically) below I confirm that this agency will be current with the National Fire Incident
Reporting System (NFRIS) prior to award. This agency understands that if this application is approved and an award issued
it also accepts the responsibility for continuing to be current in NFIRS pursuant to 20 V.S.A. § 2833.
Applicant Signature
F)
Title
Printed Name
Date
Police Service only: National Incident Based Reporting System (NIBRS)
By signing (or typing if submitting electronically) below I confirm that this agency will be current with the National Incident
Based Reporting System (NIBRS) prior to award. This agency understands that if this application is approved and an award
issued it also accepts the responsibility for continuing to be current in NIBRS reporting pursuant to VSA Title20, Section
Applicant Signature
Printed Name
Title
Date
Roger M. Marcoux Jr.
Sheriff
3 Mar II
G)
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Payment Method
Please indicate the preferred payment method and remittance address.
2 - Reimbursement in arrears of expenditures
1 - Cash Advance
with attached documentation.
Remittance Address - Street
City
State
Zip
PO Box 96
Hyde Park
VT
05655
H)
Authorization
I, the undersigned, do hereby certify under the pain & penalties of perjury that the information contained in this application is
accurate to the best of my knowledge.
eigum
Authorized Entity Signature Printed Name
AA4M/Likr.tskAA---,,_ Roger M. Marcoux Jr
Is your application complet
Thank you
e review all areas.
Title
Date
Sheriff
3 Mar II
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