Preferred Payment
Frequency -- Select One: (Other options
available upon request)
Monthly Monthly
In Arrears (30 days after signing)
Quarterly
Quarterly
In Arrears (90 days after signing)
Semi-Annual Semi-Annual
in Arrears (6 months after signing)
Annual Annual
In Arrears (1 year after signing)
No
Preference
Government Agency &
Contact Information
Government Agency Type:
Federal State
County
Municipal
School
- Public K-12, Community or State College
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: ###-###-####
