Disaster Assistance Third-Party Consent Form

Disaster Assistance Third-Party Consent Form
Authorize a third party to act on your behalf for disaster assistance matters.
Applicant's Full Name
First NameLast Name
Applicant's Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email Address
example@example.com
Applicant's Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Third Party's Full Name (Authorized Representative)
First NameLast Name
Third Party's Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Third Party's Email Address
example@example.com
Relationship of Third Party to Applicant
Type of Disaster Assistance for Which Consent is Granted
Other
Disaster Event Details (e.g., type of disaster, date, location)
Duration or Scope of Consent (e.g., valid until a specific date or for a specific task)
Applicant's Signature
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Should be Empty: