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SAFER Fire Department Information Form

*(denotes required field)

Department Name: *

Department Mailing Address *

Department Phone Number: *

Department Fax Number:

Department E-mail Address:

Chief: *

Number of Volunteers: *

Type: *

Fire
EMS
Combined Agency

Do you have a recruitment committee? *

Recruitment Coordinator Name (include rank/title):

Recruitment Committee Coordinator E-mail Address:

Recruitment Committee Coordinator Fax Number (if different):

Recruitment Committee Coordinator Phone Number (if different):

Recruitment Committee Coordinator Address:

Do you have a youth group? *

Yes
No

If yes, how many?

Do you have written, audio-visual or other materials for recruitment? *

Yes
No

If yes, would you be willing to share them with the committee? *

Yes
No

What if anything, do you think FASNY could do to assist you in your recruitment?

Enter the code above: *

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