Future Convention Dates
June 14-20, 2008 June 13-19, 2009 June 12-18, 2010
MFIRS/MAIS Number: (6 digit number - County + Station)
Full Legal Name of Company or Department:
Mailing Address: Physical Address (if different): City: , State Zip
Phone Number: Fax Number: Email Address: Web Site:
All of the Form Fields below should be numbers, please be as accurate as possible.
Response Area Population:
Number of Stations:
County: State: Billing: Fund Raising: Fund Drives: Other:
Active Volunteers: Life Members: Cadets: Fire Police: Support/Auxiliary Members: Retired Members: Inactive Members: Other Types of Volunteers: Total Volunteers: Career/Paid Employees: Total Members:
16 - 29: 30 - 39: 40 & Over:
Fire: Pre-Basic: Basic/FF-I: Intermediate/FF-II: Advanced/FO-I & Above: No Fire Training:
Rescue: Basic: Intermediate/Technician: Advanced/Specialist: No Rescue Training:
EMS: CPR: First Responder: EMT-B: CRT: EMT-P: College:
Haz-Mat: Awareness: Operations: Technician: Specialist: WMD/Terrorism: No Haz-Mat Training:
DRILL/TRAINING HOURS:
Fire: Rescue: EMS: Haz-Mat: Other: Total:
Fire/Rescue Calls: EMS Calls: Fire Prevention: Fund Raising: Administration/Meetings: Maintenance: Stand-by/Misc: Total:
The Undersigned Does Hereby Certify That, To The Best Of His/Her Knowledge, The Above Information Is True and Correct
Name of Submitting Official: Title of Submitting Official: Email Address of Submitting Official: Telephone Number of Submitting Official:
Any problems or questions should be emailed to Barry Johnson