Purchasing Division

Charlotte County Emergency Assistance Form
Purchasing Disaster Assistance Program

Charlotte County is setting up and revising a disaster assistance program in the event of an emergency, which would require outside assistance. It is estimated that this emergency assistance could be required for up to eight (8) weeks or until regular contracting procedures could be followed.

In the event your services would be required, response time is very critical. This outside support would be required within twelve (12) hours of notification. If your firm or agency would like to be included in Charlotte County Disaster Assistance Program, please complete the following on-line form or contact the Purchasing Division’s Fax on Demand system at (941) 623-1034, call path "4" and request document #300 to obtain the necessary document.

Please check the appropriate classification(s) that your firm can supply. These supplies or services shall be directly owned and be provided by your company. Subcontractors available to your company shall not be included. Firms shall list if they are currently under contract to provide emergency assistance to any other agencies.  

All information will be kept on file and updated yearly in April or May. Please provide 24-hour contact person(s) and applicable telephone numbers. Any questions for clarification please contact the Purchasing Division at (941) 743-1370.

Charlotte County Emergency Assistance Form

Date: 11/21/2009  2:46:29 PM
Business Name
Address
City State   Zip
Bus. Phone Fax Number
E-mail
Currently under contract with another agency for emergency assistance?
If Yes, please explain:

Emergency Contact Personnel

Name & Title
Home Address:
Home Phone/Cell Beeper/Cell
Name & Title
Home Address:
Home Phone/Cell Beeper/Cell
Name & Title
Home Address:
Home Phone/Cell Beeper/Cell
Name & Title
Home Address:
Home Phone/Cell Beeper/Cell

Emergency Classification List of Supplies & Services (check all that apply)

Auto & Truck Tires

Auto Parts & Repairs

Barricades, Portable

Bridge Construction

Building Materials

Chain Saws

Culvert Pipe

Electrical Utility Contractors

Electrical Supplies/Materials

Erosion Control Services

Fencing, Rental

Gas Equipment, Rental

Generators, Portable

Generators, Stationary Type

Heavy Equipment/Debris Removal

Hotel/Motel

Ice

Industrial (Rakes, Shovels, etc)

Medical Supplies

Mobile Tire Services

Pipe Line Repair

Pipe, Various

Porta-Lets

Pumps

Refrigerated Truck Rental

Resurfacing

Rock/Screening/Rip Rap

Sand & Gravel

Sandbags

Sewer Supply/Materials

Shell

Signage

Stone, Crushed

Street Construction/Repair

Street Reconstruction

Temporary Facilities (housing, restroom, offices)

Tree Removal Services

Towing, Vehicles

Utilities, Supplies

Water

Other Emergency Services Offered but not listed above, Please explain below: