ALBURGH VOL. FIRE DEPT.

REFLECTIVE ADDRESS MARKER

ORDER FORM

Please complete the following information:

Name:_______________________________________________

 

Address:_____________________________________________

 

City, State, Zip:_______________________________________

 

Phone Number:_______________________________________

 

 

ADDRESS NUMBER REQUIRED

 

_____      ______     ______     _____      _____

NOTE: If your address has fewer than 5 digits, please “X” those boxes not used.

TYPE OF MARKER

MAILBOX: ______

(Green Background with white numbers)

VERTICAL: _____      HORIZONTAL: _____

 

HOUSE: _____

(Horizontal Only)

Make Check For $15 Payable to:

 

Alburgh Volunteer Fire Department

4 Firehouse Road

Alburgh, VT 05440

 

FREE INSTALLATION FOR SENIORS OR DISABLED RESIDENTS