Exact Legal Name of Fire Company:

Full Address of Fire Company:    

City:

County:

State: 

Zip:

Telephone Number of Fire Station:

Contact Person:

Title:

Daytime Phone Number of Contact: 

Home Phone Number of Contact:

Fax Number:  

Email:

Total Acquisition Cost for Equipment:  $

Cash Down Payment:  $

Grants:  $

County or Relief Association Funds:  $

PEMA Loan (Pennsylvania Only):  $

Total to Finance:  $

Chassis Prepayment Amount:  $

Date of Chassis Prepayment: 

Amount Due Vendor at Final Delivery:  $

Date of Final Delivery:

Equipment Description (Year, Make, Model):

Type of Truck (Rescue, Pumper, Ladder, etc):

Chassis Manufacturer: 

Term (Number of years):

Payment: 

Select Monthly Annually Quarterly Semi-Annually

Method:

Select Advance Arrears

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