FY 2027 Special Equipment Request Form

FY 2027 Special Equipment Request Form

Equipment not on Approved Equipment Lists
If your agency requests trauma-related equipment not listed on the approved purchase list (ATTACHMENT B) provided, please complete the information below and submit no later than October 2, 2026, for GTC EMS Committee review.

Completed grant applications received on or before October 31st that have not submitted this form, but request unapproved equipment, will be returned to the sender.
Agency Name
County
Contact Name
Contact Title
Email
example@example.com
Requested Equipment Item
Requested Equipment Category
Requested Equipment Cost
How Will the Requested Equipment Improve Care for Trauma Patients?
Please upload any supporting invoices or additional details/reference material along with this form:

Cancelof
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If your agency is approved for the above equipment request, we will notify you by email provided above, following the EMS Committee Meeting on October 9, 2026.
Should be Empty: