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2. Today's Date*
   Today's Date
3. Name (First, MI, Last)*
5. Phone Number*
6. Email Address*
7. Fax Number
9. Incident Information
11. Incident Date**
    Incident Date*
12. Incident time* (Please also state AM or PM)
14. Incident Type*
    -- Select One --Wildland/ Grass FireVehicle FireTrash Fire Structure Fire Hay or Crop Storage FireOther Type FiresHazmat/SpillsUtility Vehicle Call with ExtricationVehicle Call No Extrication Other Type Rescue
15. Relationship to Incident
    -- Select One --OwnerTenantInsurance CompanyOther - Please state in comments
17. Incident Address
19. Comments
21. Signature of person requesting records*
23. Email*
24. Confirm Email*

26. By clicking "I agree," you agree and acknowledge that 1) your request will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

28. Do you agree?*

    1. Yes
    2. No
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30. 1. Receive an email copy of this form.
31. Email address

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32. Submit

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