Fillable Form Gen-F9 - Information Request - Columbia Fire Department printable pdf download

Form Gen-F9 - Information Request - Columbia Fire Department

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COLUMBIA FIRE DEPARTMENT

201 Orr Street, Columbia, MO 65201

573/874-7391

Fax: 573/874-7446

INFORMATION REQUEST

A minimum charge of 10 cents per page is to be assessed for the printed materials. Requests for an

additional copy or copies are to be assessed charges at the same rate as the original.

Additional charges may be assessed based on the time and effort required to compile data, and the media

cost for material provided (i.e., electronic media, photographs, maps, etc.). The hourly rate for these

services is to be based on the lowest hourly rate of the lowest paid employee.

Note: For projects estimated to exceed $10.00, a cost estimate is to be

provided and payment received prior to commencing work.

Incident Report Request:

D ate of incident:

Location of incident:

Incident Type: ___Structure Fire ___Vehicle Fire ___Investigation

____ Other

___ Automobile Accident*

___ Medical*

(*see below)

Statistical or other information Request:

Please explain:

R equested by:

Name (first, middle initial and last):

usiness Name:

Mailing Address:

City:

State:

Zip Code:

Phone Number: ___________________

FAX Number (if report is to be faxed):

Alt. Phone Number: ________________

Signature:

Date:

*IF AUTOMOBILE ACCIDENT OR MEDICAL INCIDENT:

Patient Name:

Nature of Incident:

1. Automobile Accident and/or Medical Incident Reports are to be picked up in person.

2. Valid ID is required when picking up medical reports.

3. Medical reports will be released ONLY to patient, a notarized power of attorney, or

parent or guardian if patient is under the age of 18.

GEN-F9, 03/08

Form Gen-F9 - Information Request - Columbia Fire Department

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