The form is a PDF Form which allows one to fill in the information. Once you are finished filling in the form, please save a copy of the form to your computer. This can be done by selecting "FILE" and "SAVE AS". Then you can get the form to us in any of the following ways:

1. Print the form and fax to us at 304-255-9117

2. Print the form and mail to: Raleigh County Emergency Services 162 Industrial Park Rd Beaver WV 25813

3. Send a email with the form as a attachment to: filipek@suddenlinkmail.com

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