Hawai‘i Emergency Management Agency | REQUEST FOR PUBLIC ASSISTANCE (RPA) – State and County

REQUEST FOR PUBLIC ASSISTANCE (RPA) – State and County

APPLICANT (Political subdivision or eligible applicant)*
Date submitted*
YYYY slash MM slash DD
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
Alternate Contact
First Last TITLE
BUSINESS PHONE
Fax
HOME PHONE (Optional)
Hidden
CELL PHONE
Hidden
Email*
Enter Email Confirm Email
PAGER AND PIN
QUESTIONS
Private Non-Profit Organization?
- YES
- NO
CAPTCHA