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2. Submit a Hometown Hero Request
4. First Name*
5. Last Name*
7. Address*
8. City, State*
9. Zip Code*
11. Primary Phone Number*
12. Primary Email Address*
14. Home Point of Contact*
15. Home Point of Contact Phone Number*
17. Home Point of Contact Email Address*
21. Deployment Information
23. Branch of Military
    -- Select One --Air ForceArmyCoast GuardMarinesNational GuardNavy
24. Deployment Start Date*
    Deployment Start Date
25. Deployment End Date*
    Deployment End Date
27. Copy of Mobilization Order*
31. Consent to Release Information*

    In consideration for participation in the Program, the undersigned hereby agrees to allow the City of Westfield, its respective officers, agents, officials, employees, its subcontractors or agents to enter upon the applicant’s property to perform the Services. The applicant hereby agrees to indemnify, defend, and hold harmless the City of Westfield and its respective officers, agents, officials, and employees for any and all forms of property-based claims, demands, liability, suits, damages, and judgments that arise or may arise, including for negligence, as a result of the Services being performed.

    1. No
    2. Yes
33. Disclaimer

    In consideration for participation in the Program, the undersigned hereby agrees to allow the City of Westfield, its respective officers, agents, officials, employees, its subcontractors or agents to enter upon the applicant's property to perform the Services. The applicant hereby agrees to indemnify, defend, and hold harmless the City of Westfield and its respective officers, agents, officials, and employees for any and all forms of property-based claims, demands, liability, suist, damages, and judgments that arise or may arise, including for negligence, as a result of the Services being performed.

35. Electronic Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field