Hawaii Emergency Management Agency

APPLICANT (Political subdivision or eligible applicant)*

Date submitted*

COUNTY (Location where emergency protective measures were performed)*

ORGANIZATION TYPE*

EMPLOYER IDENTIFICATION NUMBER (XX-XXXXXXX)

DUNS NUMBER (XXXXXXXXX)

APPLICANT PHYSICAL ADDRESS

Address*

Street Address Address Line 2 City State ZIP Code

APPLICANT MAILING ADDRESS

Address*

Street Address Address Line 2 City State ZIP Code

Primary Contact/Applicant's Authorized Agent

Primary Contact/Applicant's Authorized Agent*

First Last Title

BUSINESS PHONE*

Fax

HOME PHONE (Optional)

CELL PHONE

Email*

Enter Email Confirm Email

PAGER AND PIN

Alternate Contact

First Last TITLE

BUSINESS PHONE

Fax

HOME PHONE (Optional)

CELL PHONE

Email*

Enter Email Confirm Email

PAGER AND PIN

QUESTIONS

Private Nonprofit Organization?

YES
NO

IF YES, WHAT TYPE?

FACILITY QUESTIONNAIRE

(ALL RESPONSES RELATING TO THE FACILITY SHOULD BE WHERE THE EMERGENCY PROTECTIVE MEASURES (EPM) WERE PERFORMED).

NAME AND LOCATION OF THE FACILITY*

WHAT WAS THE PRIMARY PURPOSE OF THE FACILITY?*

IS THE FACILITY CRITICAL?*

Yes
No

(CRITICAL - POWER, WATER, SEWER, WASTEWATER TREATMENT, COMMUNICATIONS, EMERGENCY MEDICAL CARE)

WHO MAY USE THE FACILITY?

IS A FEE CHARGED FOR THE USE OF THE FACILITY?*

Yes
No

HOW MUCH IS THE FEE?

WAS THE FACILITY IN USE WHEN THE EMP WAS PERFORMED?*

Yes
No

DOES THE PNP ORGANIZATION OWN THE FACILITY?*

Yes
No

DOES THE PNP ORGANIZATION HAVE THE LEGAL RESPONSIBILITY FOR THE FACILITY?*

Yes
No

IS THE FACILITY INSURED?*

Yes
No

ADDITIONAL INFORMATION/COMMENTS:

REQUEST FOR PUBLIC ASSISTANCE (RPA) – PRIVATE NONPROFIT ORGANIZATION

Request for Public Assistance - Private- Nonprofit