Tdem Form – Fill Out and Use This PDF

EMERGENCY MANAGEMENT DIRECTOR/COORDINATOR NOTIFICATION

Section 418.101 of the Texas Government Code states: “The presiding officer of the governing body of each political subdivision will notify the Division of Emergency Management of the manner in which the political subdivision is providing or securing an emergency management program, identify the person who heads

the agency responsible for the program, and furnish additional pertinent information.” This form is used to make the required notification to TDEM in accordance with Governor Executive Order GA-05 submitted annually by the 1st of February of each year or within 30 days of any change of elected or appointed officials.

The information on this form may be released to those inquiring about local emergency management programs pursuant to the Texas Open Records Act. Hence, TDEM recommends that you provide business addresses and mobile telephone numbers rather than home addresses and telephone numbers.

EMERGENCY MANAGEMENT PROGRAM APPOINTMENT STATUS

I HAVE NOT appointed an Emergency Management Coordinator and will personally direct the local emergency management program.

I HAVE appointed/re-appointed the Emergency Management Coordinator identified below to conduct the emergency management program for this jurisdiction. The effective date of the appointment is: __________

We share our EMC with __________________________________ (name of jurisdiction).

If the COUNTY Emergency Management Coordinator has been appointed to other jurisdictions within the county, the County Judge and the participating City Mayors must sign this form.

(See the third page for additional signature blocks.)

The EMC for this jurisdiction is (please select one):

Paid, Full Time, EMC only

Paid, Full Time, EMC and other job duties (Fire Chief, Fire Marshal, Police Chief, EMS Director, Etc.) (please specify other duty/duties) ________________________________________________________

Paid part time, EMC only

Paid, Part Time, EMC and other job duties (Fire Chief, Fire Marshal, Police Chief, EMS Director, Etc.) (please specify other duty/duties) ________________________________________________________

Unpaid/volunteer EMC only

Unpaid/Volunteer, EMC and other volunteer job duties (Fire Chief, Fire Marshal, Police Chief, EMS Director,

Etc.) (please specify other duty/duties) _____________________________________________

Other (please describe) _________________________________________________________________

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EMERGENCY MANAGEMENT COORDINATOR

Coordinator

Asst Coordinator

Name:

Mailing Address:

City, State, Zip:

Office Phone:

Cell Number:

Fax Number:

E-mail Address:

24 Hr Contact #:

Emergency Operations Center #:

Check this box if the information above contains personal information pertaining to a law enforcement official such as personal home or cellular phone number, and/or home mailing or personal email address.

Judge’s or Mayor’s Signature

Date

PLEASE RETURN TO:

Texas Division of Emergency Management

Operations Section

P.O. Box 15467 Austin, TX 78761

Phone: (512) 424-2208		Email: soc@tdem.texas.gov

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FOR SHARED EMC USE ONLY

By signing this form, you agree the appointed Emergency Management Coordinator (EMC) listed on page two is also your EMC. If you have a separate EMC, you must submit the first and second pages for your jurisdiction.

Mayor

City:

Name:

Mailing Address:

City, State, Zip:

Office Phone:

Cell Number:

Fax Number:

E-mail Address:

Signature:

Mayor

City:

Name:

Mailing Address:

City, State, Zip:

Office Phone:

Cell Number:

Fax Number:

E-mail Address:

Signature:

Mayor

City:

Name:

Mailing Address:

City, State, Zip:

Office Phone:

Cell Number:

Fax Number:

E-mail Address:

Signature:

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