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2. Franklin County Department of Public Safety • 1488 Franklin Street • Rocky Mount, VA 24151 • 540-483-3091
4. Property Owners may request a fire incident report free of charge. Please complete this form and submit.
   
   ALL OTHERS: The cost is $10.00. Please bring or mail your payment to the above address and make check payable to Franklin County Department of Public Safety.
   
6. Name*
7. Company Name (if applicable)
9. Street Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number where you can be reached*
15. Fax Number
16. E-Mail Address
18. Date of Incident*
    Date of Incident
19. Address of Incident*
21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application 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.
23. Electronic Signature*
24. Today's Date*
    Today's Date
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field