2. Preferred Method of Delivery?*

   1. E-Mail
   2. Fax
   3. Regular Mail
   4. Walk-In
3. Date of Request*
   Date of Request
4. Time*
   Time
8. Requestor Information
10. First Name*
11. Last Name*
13. Address *
15. City*
16. State*
17. Zip*
19. Phone Number*
20. Fax Number if Applicable
22. Email Address*
26. Incident Information for Report
    Fire Incident Reports are subject to open records; however, an emergency medical record/report will require the patient, legal guardian, or power of attorney to provide photo identification. When a person other than the patient requests an emergency medical record/report, a notarized HIPAA authorization form or court order is required. Copies of emergency medical records/reports must be picked up in person.
28. Type of Incident*
    -- Select One --Building FireVehicle FireFire - OtherEmergency Medical CallMotor Vehicle AccidentWeather Related EmergencyOther
30. Address of Incident*
32. City
33. State
34. Zip Code
36. Date and Time of Incident*
    Date and Time of Incident

    Date and Time of Incident
37. Marietta Fire Incident/Case Number
39. Any Additional Details for Request
41. Government issued photo ID (when required)
42. Authorization Document (when required)
46. Signature of person making the request*
    The City will respond to this request within five (5) working days.
48. Do you agree?*

    By clicking "I agree," you agree and acknowledge that 1) your application will not be "Signed" in the sense of a traditional paper document and 2) By signing in this alternate manner, you agree that your "electronic signature" is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I Agree
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