NAME OF APPLICANT REQUESTING REPORT APPLICATION DATE
REPORT TO BE MAILED TO
(COMPLETE ADDRESS INCLUDING NAME, COMPANY, STREET ADDRESS AND ZIP CODE)
TELEPHONE NUMBER OF APPLICANT
— PLEASE PRINT —— PLEASE PRINT —
— PLEASE PRINT —— PLEASE PRINT —
— PLEASE PRINT —
CITY OF PHILADELPHIA
DEPARTMENT OF RECORDS
COMPLETE THIS BLOCK FOR FIRE REPORT:
COMPLETE THIS BLOCK FOR EMS REPORT:
DATE OF FIRE TIME ADDRESS OF FIRE
DATE OF SERVICE TIME NAME OF PATIENT
IF YOU HAVE A DISABILITY AND REQUIRE AN ACCOMMODATION IN ORDER TO COMPLETE THIS FORM AND/OR
TO PARTICIPATE IN A PROGRAM OR SERVICE, CONTACT THE ADA COORDINATOR AT
(215) 686-2266.
FEE
(for search and/or copy—$20.00) — NON-REFUNDABLE
TO APPLICANT: THIS IS A COPY OF THE APPLICATION FORWARDED TO THE FIRE DEPARTMENT: Your report will be prepared and mailed directly
to you by the Fire Department. ALL INQUIRIES AFTER SUBMISSION, CALL (215) 686-1366 AND REFER TO APPLICATION NUMBER ON FORM.
LOCATION OF INCIDENT
(EXACT STREET LOCATION WHERE INCIDENT OCCURRED)
82-311 (Rev. 2/06) PLEASE DO NOT CALL DEPARTMENT OF RECORDS AFTER SUBMISSION OF APPLICATION
APPLICAAPPLICA
APPLICAAPPLICA
APPLICA
TION FOR FIRE TION FOR FIRE
TION FOR FIRE TION FOR FIRE
TION FOR FIRE
AND/ORAND/OR
AND/ORAND/OR
AND/OR
EMS REPORTEMS REPORT
EMS REPORTEMS REPORT
EMS REPORT
PLEASE DO NOT SUBMIT AN APPLICATION WITH INSUFFICIENT OR INCORRECT
INFORMATION; MAY RESULT IN "REPORT NOT FOUND."
CITY OF PHILADELPHIA • DEPARTMENT OF RECORDS
APPLICATION FOR FIRE AND/OR EMS REPORTS
REQUEST MUST HAVE DATE AND LOCATION OF FIRE AND/OR EMS INCIDENT.
REQUESTS FOR EMS REPORTS REQUIRE A COMPLETED AND SIGNED "AUTHORIZATION
FOR RELEASE OF PA EMS REPORT" FORM; MUST BE NOTARIZED IF ORDERED VIA U.S. MAIL
OR IF APPLIED FOR BY OTHER THAN PATIENT IN PERSON AT DEPARTMENT OF RECORDS.
SUBMIT APPLICATIONS TO:
DEPARTMENT OF RECORDS
ROOM 167, CITY HALL
PHILADELPHIA, PA 19107
(215) 686-2266
FOR INQUIRIES AFTER SUBMISSION CALL PHILADELPHIA FIRE MARSHALL (215) 686-1366.
TO EXPEDITE SERVICE, PLEASE SEND 2 SELF-ADDRESSED, STAMPED ENVELOPES.
MAKE CHECKS OR MONEY ORDERS PAYABLE TO "CITY OF PHILADELPHIA".
$20.00 FEE IS NON-REFUNDABLE
PLEASE ALLOW 6 TO 8 WEEKS TO RECEIVE COPY OF REPORT OR NOTICE OF "REPORT NOT FOUND".
