FAIR LAWN OFFICE OF EMERGENCY MANAGEMENT
Please
print this form, complete it, and return it to the Fair Lawn Office of
Emergency Management. Our office is located at Borough Hall and can be
dropped off, mailed to the Fair Lawn Office of Emergency Management,
8-01
Fair Lawn Avenue, Fair Lawn, New Jersey 07410, or faxed to: (201) 703-4266.
You can also send it via e-mail by copying, pasting, and completing the form to
If you have any questions, call (201) 794-5390.
Fair Lawn Emergency Management
8-01 Fair Lawn Avenue
Fair Lawn, New Jersey 07410
201-794-5390 – 201-794-1506 (fax)
NAME: ________________________________________________
Address: ________________________________________________
________________________________________________
Home Phone #: _____________________ Cell Phone #: ______________________
Email: ____________________________________
Please describe the special needs / assistance that may be required (i.e., oxygen, medical device, mobility challenge, wheelchair, etc.).
__________________________________________________________________________
__________________________________________________________________________
Do you need electric power to operate medical equipment? Yes No
Do you have a back-up generator that will activate upon loss of power? Yes No
In case of an emergency, please contact: __________________________________________________
Name Relationship
Home Phone #: ______________________ Work Phone #: ___________________________
Cell Phone #:________________________ Email: __________________________________
Does a family member or neighbor have a key to your residence in case of an emergency?
If YES, please complete:
Name:_____________________________ Home Phone #: ___________________________
Address: ___________________________ Work Phone #: ___________________________
Cell Phone #: _______________________
PLEASE NOTE
Resident and/or Emergency Contact are responsible for any updates or changes to the information submitted!