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FIRESafe MARIN Chipper Day Award Application

Full Name(*)
Please type your full name.

E-mail(*)
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Phone(*)
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Street Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Are you submitting this application on behalf of an organization?(*)
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For example: a homeowner's association, fire department, neighborhood group, community group.

If "Yes," Please provide a name and mailing address for your organization.
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If your organization has a Tax ID number or EIN, please provide.
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Project Description

Describe your project.(*)
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Describe the project, in detail: include a description of the neighborhood, details of the exact (or estimated) locations of the work to be completed, the nature of the work to be completed, estimation of the total acreage to be "treated," description of the existing fuels, and the fire problem.

Why is your neighborhood a good candidate for "Chipper Day" or "VMP" funding? (*)
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Describe past actions to reduce wildfire hazards in the affected neighborhood(s).(*)
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List the individuals, organizations, and agencies that you expect to cooperate in the completion of this project.
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Include: homeowner's associations, neighborhood groups, individual landowners (if possible), businesses, fire departments, land management agencies, or public entities.

Funding Requested (in $ dollars)(*)
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Matching Funds (in $ Dollars)(*)
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Project Photos

Please upload at least three "before" photos of the vegetation fuels that you intend to remove with the funds from this project. Take care to submit photos that clearly depict the fire hazards, and if possible, the property that will be protected when the treatment is complete. You will be required to submit "after" photos when the work is complete, as part of the federal documentation.

Additional photos or documents may be emailed to grants@firesafemarin.org. Be sure to specify the application that the photos or documents are related to in the email message.

Upload project image 1 (5MB max)
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Upload project image 2 (5MB max)
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Upload project image 3 (5MB max)
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When would you anticipate starting work on this project?(*)
Please select a date when we should contact you.

Please select the earliest date that work might begin.

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted for this award, any false statements, omissions, or other misrepresentations made by me on this application may result in withdrawal of the award. I understand the federal funds may be applied to the project, if approved, and all documentation and support requirements must be completed on-time in order for FIRESafe MARIN to provide funding.

INDEMNIFICATION: Upon electronically signing this document the below, stated applicant hereby assumes and agrees to protect, hold harmless and indemnify FIRESafe Marin and its officers, agents and employees from all legal liability for property damage, injury to or death of all persons whomsoever resulting from the FIRESafe Marin Chipper Day Award Program.

Enter your full name as a signature.(*)
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Entering your name signifies that this person filled out this form, and agrees to the terms set in this application and agreement.

How should we contact you?(*)

Enter the text shown in the image.(*)
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FIRESafe MARIN   |   P.O. Box 2831  |   San Anselmo, CA 94979   |   (415) 570-4FSM {4376}   |   info@firesafemarin.org


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