Name
Title
Agency
Address
City
State
Zip
Phone (Day)
Phone (alternate)
Fax
E-mail

Select maximum budget for this project:
(required to verify whether selected apparatus can be manufactured within the budget range or not)

150,000 - 200,000 200,000 - 250,000 250,000 - 300,000 300,000 - 350,000 350,000 - 400,000 400,000 - 500,000 500,000 +
Proposal required for following reason:

Budget Planning Grant Application Immediate Purchase Future Purchase

Information needed not later than:
(specify in box below)



Select primary mission of vehicle:

Conventional Rescue Technical Rescue (USAR) - Truck Technical Rescue (USAR) - Trailer Haz-mat - Truck Haz-mat - Trailer Air and Light only (breathing compressor system) Air and Light in addition to other selected functions Other

If OTHER selected above, provide brief description in box below or use this box for more specifics about selected mission:



Is there an overall height restriction?
If so, specify in box below



Is there an overall length restriction?
If so, specify in box below



Is there a model shown in our Delivery section that is similar to what is required? If so, specify in space below.
If so, specify in box below



Preferred Chassis:

Freightliner International Spartan Custom Other

If OTHER selected above, specify in box below:



Chassis Requirements:

Check applicable boxes