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DEPARTMENT INFORMATION:

*Dept. Name: * First: * Last: Title:             * Address:   * City: * State: * Zip:     * County:     * Day Phone: Night Phone: Fax:     * Email:

* Do you wish to receive a starter package (contract, pricing worksheet, W9, tax-exempt certificate) by email?       YES       NO

Annual Call Volume:

Does your Department currently bill for service?       YES       NO

What services does your department provide?

EMS First Response  Fire Services  Rescue Service  Hazmat Services  Ambulance Transport

Your Department is currently a:

 Rural Fire Protection District    Emergency Services District    Municipal District

 Other - explain:
      Under contract with:    ESD    RFPD

How did you hear about us: -- please select one -- Internet search Direct mail Advertisement (please type publication name below) Salesperson (please type salesperson name below) Referral (please type referrer name below) Other (please elaborate below)
     Advertisement/Salesperson/Referral/Other:

Please type any questions or additional information you may have: