2. 
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. What is the address or location of the incident?*
12. City
13. State
14. Zip
16. What is the date of the incident?*
    What is the date of the incident?
17. What is the approximate time of the incident?*
19. What is the type of incident?*

    1. Structure Fire
    2. Mobile Property (Vehicle) Fire
    3. Outside Fire (Including vegetation, rubbish)
    4. Motor Vehicle Accident
    5. Emergency Medical Call
    6. Hazardous Materials Call
    7. Fire Alarm
    8. Other
20. If other, please specify.
22. How would you like to receive this report?*

    1. Email it to me.
    2. I will pick it up at Fire Headquarters
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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