HELP NJ EMS NEEDS Page Survey

This page is intended for NJ EMS Agencies in need of help due to Hurricane Sandy. 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 you to contact those with donations matching your needs. All arrangements for delivery and/or tax information of the gift are between you and the donor.

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Your EMS Agency's Name

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Your Last Name

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Your First Name

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Agency location (please include a primary contact email and phone number)

Agency location (please include a primary contact email and phone number) Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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Please select the County in which your agency is located:

Please list what items your agency is in need of:

Please list what items your agency is in need of: Item 1
Item 2
Item 3
Item 4
Item 5

How many of each item does your agency need?

How many of each item does your agency need? Item 1 Quantity
Item 2 Quantity
Item 3 Quantity
Item 4 Quantity
Item 5 Quantity

Are you able/willing to pick up the items from the donor?

Are you able/willing to pick up the items from the donor? Yes

No