Form Center

2. Requester Information:
4. Agency Name:*
   Agency making request
5. Point of Contact Name:*
   Who should we contact if needed?
7. Phone Number:*
   Contact phone number
8. Alternate Phone Number:
10. Start & End Date/Time of Requested Deployment:*
    Start & End Date/Time of Requested Deployment: Start Date

    Start & End Date/Time of Requested Deployment: Start Time

    —

    Start & End Date/Time of Requested Deployment: End Date

    Start & End Date/Time of Requested Deployment: End Time
12. Location of Deployment Request*
14. Describe the concept of operations for the deployment request:*
18. Please check all items that your agency acknowledges or agrees to provide during the MEOC deployment:
    If selecting checkboxes for ICS-205 Incident Radio Communications Plan or MEOC Frequency Authorization Form click on applicable form to download to your computer. Fill out, save, and upload completed documents when submitting this form.
20. Check applicable

    1. Pay telephone expenses (per min) for calls made/received while MEOC is on-site upon receiving invoice from Cole County
    2. Will provide facilities for MEOC crew personal hygiene & rehab (showers, restrooms, bunkroom)
    3. Cover expenses related to any/all damages to MEOC or equipment while on site
    4. Provide meals for MEOC crew and security detail
    5. Provide fuel or pay fuel expense for MEOC while on site (approx 100 gallons/week of operations)
    6. Have signed Missouri State Interoperability Executive Committee VHF/UHF MOU, and have the applicable channels programmed into our agency radio equipment
22. Check if applicable

    1. Have completed MEOC frequency authorization and sharing MOU

    *See forms below
24. MEOC Frequency Authorization Form (pdf)
    FREQUENCY SHARING MEMORANDUM OF UNDERSTANDING / AUTHORIZATION TO USE RADIO FREQUENCIES
25. ICS-217A Form (.xlsx)
    ICS-217A

    This worksheet goes with MEOC Frequency Authorization Form
27. Check if applicable

    1. Have completed ICS-205 (Incident Communications Plan) (form below)
29. ICS-205 Incident Radio Communications Plan (.xlsx)
    Paging and Speed Dial Inventory Sheet
31. check

    1. Will require additional telephone lines via satellite at rate of $50.00/month(1-month minimum – bandwidth charges excluded).Indicate how many lines you will need in text box below).
33. Number of additional lines via satellite needed:
    How many lines via satellite are needed? Rate of $50/mo.
35. Check applicable

    1. Will require additional Internet access bandwidth at a rate of $875.00/day or $5,000/week
    2. Will provide external power for MEOC in accordance with published ‘Power FAQ’ document
    3. Will require FAX services and will pay utilization costs billed in increments of $10.00
37. check

    1. Will provide additional telephone lines. Indicate B-1 (max 4) or T1/PRI (max 1) circuit types. (choose below)
39. Circuit Types:

    1. Analog Loop Start

    1. T1 Channelized

    1. ISDN PRI
43. Equipment Use Agreement
45. This is an agreement between the Cole County/Jefferson City Emergency Management Agency (lender) and (borrower)
46. (Borrower)*

    Borrower's name here

48. for use of equipment -
49. Equipment Kind/Type

    Equipment kind/type

51. from/to (date) -
53. Date From/To*
    Date From/To Start Date

    Date From/To Start Time

    —

    Date From/To End Date

    Date From/To End Time

    Start date

55. Equipment Use

    Under the normal exchange of equipment both parties agree that the individual assigned to operate the equipment must be trained on the operation of and recognizes the hazards of the equipment. Borrower will have a certificate of insurance and adequate insurance to cover damages. 

    The borrowing agency shall indemnify and hold harmless Cole County to the fullest extent permitted by the laws of the State of Missouri in effect at the time against and in respect of any and all actions, suits, proceedings, claims, demands, judgments, costs, expenses (including advancement of reasonable attorney’s fees), losses, and damages resulting from Burrowers good faith performance of duties and obligations with the Cole County. 

    The borrowed equipment must be returned to the owner in the condition it was received. The borrower is responsible for all reasonable repairs including parts and labor should malfunction or damage occur during the borrowing period. Inspection of equipment is encouraged before taking possession. Equipment use authorization form must be completed and signed before taking possession of the equipment.

    Borrowing party is responsible for all liability, losses, damages, costs or expenses which arise out of the negligent act or omission of the equipment user while acting in the course of their involvement with the above mentioned agreement.

     For normal exchange of vehicles or equipment, a minimum of seven working days’ notice must be given to the lender prior to expected date of use. All completed and authorized documents must be received by the lender two days prior to the expected date of use. Equipment use is for a 24 hour period. Extensions may be granted by appropriate personnel.

     In the event of an emergency in which there is an identified need for the retrieval of equipment to respond to such an emergency, property will be retrieved by lender at little to no notice.    

    Please sign the Electronic Signature Agreement below if you agree with these terms  

57. Borrower Name:*
58. Borrower Title*
59. Agency*
61. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
63. Electronic Signature
65. Upload required documents (if applicable):
    Upload completed ICS-205 Incident Radio Communications Plan and/or MEOC Frequency Authorization Forms
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field