minnesota department of Disaster Assistance Volunteer Form

labor & industry

The purpose of this form is to expedite volunteer inspection assistance available following a disaster.
Note: Submittal of this document does not obligate anyone to participate if contacted.

THE INDIVIDUALS LISTED BELOW HAVE BEEN AUTHORIZED TO REPRESENT:

Name of organization or company:________________________________________________
Organization or company main phone: _____________________________________________
Submitted by: (print name and title) __________________________________________________________________
Signature: _____________________________ Phone: ___________________ E-mail: ________________________

The organization/company is responsible for notifying each individual included on this list and
providing appropriate information regarding their organization authorization policies and procedures.
Please include this information in your Disaster Plan. Remember - the best way to prepare and train
for a disaster is to assist with the aftermath of a disaster in another municipality.

NAME and EMAIL ADDRESS TELEPHONE TELEPHONE TELEPHONE AVAILABLE FOR THESE ELECT PLUMB HVAC BLDG CLERICAL
REGIONS (SEE MAP):
PLEASE PRINT CLEARLY WORK HOME (OPTIONAL) MOBILE (CIRCLE ALL THAT APPLY)

1 2 3 4 5 6 ALL
Building Official No._________     
1 2 3 4 5 6 ALL
Building Official No._________     
1 2 3 4 5 6 ALL
Building Official No._________     
1 2 3 4 5 6 ALL
Building Official No._________     
1 2 3 4 5 6 ALL
Building Official No._________     
1 2 3 4 5 6 ALL
Building Official No._________     
Mail to: Attn: William Mesaros, Construction Codes and Licensing Division, 443 Lafayette Road N., St. Paul, MN 55101-2181
GI019
www.doli.state.mn.us