2019 Chesney Fallen Firefighters Memorial Grant Program Application

Grant Application
Please complete all items. Questions with an asterisk (*) require an answer. IMPORTANT NOTE: This application must be completed in its entirety at the time of submission and is unable to be saved to work on as you go. You are encouraged to download the PDF file,"INFORMATION NEEDED FOR GRANT APPLICATION," to work on your answers in a saved document and then copy/paste your responses into the online application.
Fire Chief/Fire Department Information (NOTE: The Fire Chief is required to sign the grant contract for the application to be considered complete.)
Name (Fire Chief):*
First Last
Title:*
Name of Fire Department applying for grant:*
Fire Department Compliance Number:*
Note: Compliance numbers can be obtained from the Georgia Firefighters Standards and Training Council. Applications without compliance numbers will not be considered.
Department Type*
- Paid
- Volunteer
- Combination
What is the size of your fire department (i.e. staffing numbers)?*
What is the population of the departments jurisdiction?*
What is the per capita income of the departments jurisdiction?*
Mailing Address:*
Street Address Address Line 2 City State ZIP Code

Implementing Personnel Information (NOTE: This is the person who will be responsible for implementing grant funds if awarded.)
Name (Implementing Personnel):*
First Last
Title:*
Name of Fire Department:*
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Daytime Phone Number:*
Email:*

Note: This email address will be used for all communication regarding the grant, including confirmation of online application submission.
Select relevant professional qualifications of the person responsible for implementing the program/project (listed above). Check all that apply.*
- Fire and Life Safety Educator
- Firefighter
- Active in Fire and Life Safety Education (current professional responsibilities)
- Youth Firesetter Intervention Specialist
- Other
If other, list qualifications:*

Program/Project Specific Information
In as much detail as possible provide a description of your program/project that these funds would support including your target audience. Be specific.*
Is this a new or existing program/project in your department?*
- New
- Existing
Explain the need for the program/project.*
Describe how you will evaluate your program/project. Be specific and consider a variety of methods.*
Please refer to the resources provided under "Helpful Links for Grant Writing Resources" just below "Application and Supporting Documents" on the Chesney page.
Provide a schedule with a specified time frame for your program/project completion.*

List other groups/agencies who partner with you on this program. If you are not partnering with anyone else, skip this section.
Name One of Group/Agency partnership:
First Last
Address One of Group/Agency partnership:
Street Address Address Line 2 City State ZIP Code
Name Two of Group/Agency partnership:
First Last
Address Two of Group/Agency partnership:
Street Address Address Line 2 City State ZIP Code
Name Three of Group/Agency partnership:
First Last
Address Three of Group/Agency partnership:
Street Address Address Line 2 City State ZIP Code
Name Four of Group/Agency partnership:
First Last
Address Four of Group/Agency partnership:
Street Address Address Line 2 City State ZIP Code

File Upload (Optional)
You have the option to upload the required files for the application instead of mailing hard copies if you would like. Please only send PDF, Word, Excel, or JPEG files. Maximum file size is 128MB.
Drop files here or

Grant Application