2. If you are a resident of the City of Ormond Beach and are physically unable to fill a sandbag, or to unload a prefilled sandbag from your vehicle, you may submit this form to request that sandbags be delivered directly to your residence. Please provide accurate contact information to ensure your request is reviewed and arrangement for delivery can be made.
4. Date*
   Date
6. First Name*
7. Last Name*
9. Street Address*
11. Suite / Apartment
13. City*
14. State*
15. Zip*
17. Contact Phone Number*
18. Email Address*
20. Number of Requested Sandbags (maximum of 10)*
22. Instructions:
    Upon approval, Public Works will coordinate a one-time delivery of prefilled sandbags. The applicant is responsible for the placement of sand bags at his or her residence. If you have questions, please call the Public Works Department at 386-676-3220.
24. By submitting this form I certify that I am not physically capable of collecting or filling sandbags, or unloading a prefilled bag from a vehicle; and that I do not have someone living in my residence who can do so on my behalf.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field