MDERS T&E Trailer Request Form

All MDERS stakeholders must complete T&E Trailer Request form to gain access to the MDERS Training & Exercise Trailer and/or its contents. All requests will be vetted and approved by MDERS staff. Once a decision has been made, the requestor will be notified using the contact information provided in the form. This form MUST be submitted prior to using the trailer.

MDERS Partner Organzation *

Steering Committee Contact *

Primary Point of Contact *

First

Last

Email *

Phone *

Alternate Point of Contact *

First

Last

Alternate Email *

Phone *

Tow Vehicle *

Reason for Request *

Description of Event *

Location of Event *

Address Line 1

Address Line 2

City

State

Zip Code

Need Priority

Please indicate the level of need. (Low=1, High=5)

Requested Pick-Up Date *

Date

Time

Anticipated Return Date *

Date

Time

Reviewed By:

Signature

Comment