Please print clearly or type.
SECTION 1 – Fire Department Contact Information
Fire Department Name:
County:
Mailing Address:
City:	State:	Zip:
Fire Chief Name:
Cell Phone:	Work Phone:
E-mail:
SECTION 2 – Equipment Request (check all that apply)
Equipment Requested	Remarks/Comments
Pickup Truck
Generator (5kw up to 60kw)
Fire Truck/Pumper
Tender (Tanker Truck)/10-Wheeler
4x4 Cargo Truck
6x6 Cargo Truck
Other
Note: Only one (1) of each item above may be requested.
SECTION 1 – Agreement
By signing this form, you are giving the Virginia Department of Forestry (VDOF) the right to screen an item on behalf of your fire department. You are also stating that if you currently have any federal excess property, the inventory is up to date, and the equipment is used per the agreement.
Cooperator Authorized Person Name (Print)	Cooperator Authorized Person Title
Cooperator Authorized Person Signature	Date
Mail or fax original request to: Virginia Department of Forestry Federal Excess Property Coordinator 900 Natural Resources Drive, Suite 800 Charlottesville, VA 22903 Fax: (434) 977-9839	Note: Requests for equipment will be filled on a “first-come, first-served basis”. This request will be active for two years. If you wish to keep it active longer and remain in the same place on the list, you will need to complete another request and MAIL the original to VDOF.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). USDA and VDOF are equal opportunity providers, employers and lenders. All information related to this program is subject to the Freedom of Information Act.