Representative:   Alternate: Designation: Designation: Telephone Number: Telephone Number: Pager: Pager: Fax Number: Fax Number: Email: Email:

Annual Membership Fee is $1000.00 / $2000.00 as indicated by TTEMAS payable by 31st January. Make cheques,draft, etc. payable to Trinidad and Tobago Emergency Mutual Aid Scheme. Complete form and promptly submit it, deliver payment to TTEMAS. All Members agree to maintain resources to meet likely emergencies. Members shall be bound by TTEMAS By-Laws

Nature of Business: Number of Employees: Mayor Hazards:

Resources Availability Ambulance (specify type) Extrication Tools Trauma Kits, Resuscitators, Stretchers Fire Truck Water Water/Foam Dry Chemical Water/Foam/Dry Chemical HAZMAT Trailer Foam (Type / % /Amt) Form Eductors Portable Monitors Water Pumps Hoses (Size/ Amt/ Thread) Hard Suction Hose Large Diameter Hose SCBA's SCBA's Spare Bottles Portable Casacade Air Supply Auxiliary Lighting Plants Oxygen Analzyers / Explosimeters Absorbent Pillows / Booms Emergency Radio Communications Current Tested Emergency Respone Plan Personnel Available & Times Other Equipment / Materials