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2. 
4. Radio Request Form
6. Date of Request
   Date of Request
7. Requesting Department/Agency
9. Requested by
10. Requestor's Role
    -- Select One --ChiefCaptainLieutenantOther
12. Requestor's Phone Number
13. Requestor's Email
15. Reason for Request

    Insurance Form must be completed for Stolen/Damaged radios; damaged/destroyed radios must be returned.

    1. New Member
    2. Lost/Stolen Radio
    3. Damaged/Destroyed Radio
16. Radio to be Issued to
17. PTT ID
19. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 

    • 1) your submission will not be signed in the sense of a traditional paper document, 
    • 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 
    • 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
21. Electronic Signature*
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field