Application name
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First Name:
Last Name:
Email:
Department Name:
Department Zip Code:
Size of Department:
0-50
50-100
100-200
200-300
300-400
400-500
500+
Type of Department
Volunteer
Fully Paid
Part Paid
Fire Response
Number of residential structure fires
Number of non-residential structure fires
Number of vehicle fires, if structural turnouts are used
Number of Incidents, such as alarm sounds or other incidents where structural gear is worn
Do you have a policy that requires high visibility vests?
Yes
No
Is there currently a maintenance program in place?
Yes
No
How much money was spent on moisture barrier repairs? If available
How much money was spent approximately on rips and tears? If available
How much money was spent approximately on abrasion related repairs? If available
How much money was spent on hook and loop repairs? If available
How much money was spent on abrasion of non-reinforced areas? If available
How much money was spent approximately on repairs to the outer shell? If available
How much was spent on cleaning, inspection, and repairs of structural protective clothing? If available