Department Name:

Department Address:

City:    State:    Zip Code:

Contact Person:    Rank/Title:

Email Address :

Telephone: Ext.    Fax:

Population Served:    Square Miles:

ISO Rating:    Last Date Certified:

Pumpers: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+    Ladders: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+    Rescue: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+    Tankers: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

Support Vehicles: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+    Ambulance/Other: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+    Reserve: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+

What year is your newest apparatus?    Oldest?

What is your time frame for your next apparatus purchase? Choose one... Immediately 1-3 months 4-6 months 7-9 months 10-12 months More than a year

How soon are you looking to start the process? Choose one... Immediately 1-3 months 4-6 months 7-9 months 10-12 months More than a year

Would you like a representative from EWFAC to contact you? Yes No