Membership Form

Our goal is to protect life and property with current training and updated equipment. With your membership fees, donations, and assistance we can accomplish this as a community. Any questions, comments, or complaints are welcome. Thank you!

Sincerely,

Central Polk County Fire Rescue Board of Directors

Instructions:

1) Calculate fee based on schedule:

It is the responsibility of the property owner to provide coverage for rental real estate. Tenants are responsible for providing coverage for their personal property.
Commercial property = $100.00 per year
- Up to five (5) properties. Additional properties at $35.00 per year per property. (This does not include your primary residence.)
Single family residence = $65.00 per year
Senior citizen's single family residence = $55.00 per year
- Must provide proof of eligibility (age 55 or older). (This does not include commercial property.)

2) Fill out and submit form.

3) Print completed form and mail it along with the correct fee.

4) To ensure accurate and timely response to your emergency situation, PLEASE have address numbers prominently displayed at the roadside.

Your name: *required
Your phone number: *required
Owner name (if different than above):
Owner phone number (if different than above):
Business name (if commercial property):
Physical, 9-1-1 address of property to be covered: *required
Your mailing address (if different than 9-1-1 address, such as PO Box):
Emergency contact person (keyholder or family member not located at this location): *required
Emergency contact phone number: *required
Number of residents/employees at this location: *required
Any special medical concerns (such as bedridden, altered mental status, etc.):
     *required (enter "none" if none exist)
Number of stories: *required
Basement? *required
Approximate square footage (sqft) of ground floor: *required
Building construction: *required
     Type 1 - Fire resistive (steel and/or concrete walls and roof)
     Type 2 - Non-combustible (steel and/or concrete walls with combustible roof)
     Type 3 - Ordinary construction (wood walls and roof with brick exterior)
     Type 4 - Heavy timber (large wood beams and columns such as log cabin)
     Type 5 - Wood frame (2x4 and 2x6 wood frame construction walls and roof)
List of chemicals on property (other than small quantities of household chemicals):
     *required (enter "none" if none exist)
List of hazards on property (such as animals, propane tanks, etc.):
     *required (enter "none" if none exist)