First Name *

Last Name *

Title *

Company *

Mobile Phone *

Email *

Department Website *

What type of department do you work for? * VolunteerCareer/PaidCombination: Volunteer & Career/PaidIndustrialMilitaryOther

Are you currently participating in selecting products or services for your department or organization? * YesNot currently but I will in the next 12-18 monthsNo

Which best describes your role for purchasing products or services? * I am the final decision makerI influence decisions that are madeI am not responsible for decisions

Give a brief description of your current product or service needs: *

What is your department's current staffing strength of Paid career firefighters? Please provide an estimate *

What is your department's current staffing strength of Paid EMTs? Please provide an estimate *

What is your department's current staffing strength of Volunteer Firefighters? Please provide an estimate

What is your department's current staffing strength of Volunteer EMTs? Please provide an estimate

Any colleagues who would be a good fit for the FDIC MATCH program? (Please provide Colleague's name, title and email)

Comments