Preferred Payment
Frequency -- Check One: (other options
available upon request)
Monthly in Advance Monthly
In Arrears
Quarterly In Advance
Quarterly
In Arrears
Semi-Annual
in Advance Semi-Annual
in Arrears
Annually
in Advance Annual
In Arrears
No
Preference
Preferred First
Lease Payment Date:
(At closing, or 1,
3, 6 or 12 mo. after closing)
Agency &
Contact Information
Government Agency Type:
Federal State
County
Municipal
OR any of the following types of firedepartments:
Rural
Fire District
Fire
Protection District
Volunteer
Fire Department (100% Tax Supported)
Volunteer Fire Department (Non-Profit Corp.)
Agency Name:
*
City & State
* *
First Name:
*
Last name
*
My Title:
E-mail:
*
Agency Phone:
* Ext:
use this format: ###-###-####
(Optional)
Contact Phone:
Cell
Phone
Office
Direct LineOther
use this format: ###-###-####