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2. Effective Date*
   Effective Date
4. Fire Department Name*
6. Station #*
7. County*
9. Mailing Address*
11. City*
12. State*
13. ZIP*
15. Phone Number*
16. Fax Number*
18. Email Address*
19. Website*
21. Drill Night*
    -- Select One --MondayTuesdayWednesdayThursdayFridaySaturdaySunday
22. Email address for all billing and company statements*
26. Physical Address (if different than mailing)
28. City
29. State
30. ZIP
34. Chief's Name*
35. Daytime Phone #*
37. Cell #*
38. Email Address*
42. Training Officer's Name*
43. Daytime Phone #*
45. Cell #*
46. Email Address*
50. May we use your email address in broadcast emails?
51. Chief*

    1. Yes
    2. No
52. Training Officer*

    1. Yes
    2. No
54. Do you wish to receive broadcast emails?
55. Chief*

    1. Yes
    2. No
56. Training Officer*

    1. Yes
    2. No
58. Who should be contacted first concerning registration problems?*

    1. Chief

    1. Training Officer
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field