HELP NJ EMS Donation Page Survey

On behalf of the EMS Community, we thank you for your generosity! Through the collection of this survey information, a database will be developed for those willing to give and those in need. Please fill out the following request which will be posted for public viewing on the Department website at www.state.nj.us/health.ems. It will be up to agencies in need to contact you regarding donations matching their needs. All arrangements for delivery and/or tax information of the gift are between you and the recipient.

You Agency's Name (If Applicable):

*

Your Last Name

*

Your First Name

*

Contact Information

Contact Information Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

*

Please select the County in which you are located:

Please list what items you are able to donate:

Please list what items you are able to donate: Item 1
Item 2
Item 3
Item 4
Item 5

How many of each item can you donate?

How many of each item can you donate? Item 1 Quantity
Item 2 Quantity
Item 3 Quantity
Item 4 Quantity
Item 5 Quantity

Are you able/willing to help deliver items to the needed locations?

Are you able/willing to help deliver items to the needed locations? Yes

No