SAFEWAY

Frevdene tre Coentmmney Srairnt é

: Offisial Mascot of
; the Firebuster Program

C0 es FIREBUSTER TRAUMA PUP REPORT FORM

Pup Number;

Complete form in duplicate, retain one (1) copy for your files

Fire Department:

Apparatus Number: Date of Issue
Report Number : Reporting Officer ;
Child's Full Name : | Age :

Child's Address :

Reason for Issue :

Firebuster Pups are provided to your department as a community
service by Canada Safeway. In order to receive replacement Pups
this completed form must be returned to:

FOR OFFICE USE ONLY
G.V.R.D. FIRE CHIEF'S ASSOCIATION

FIREBUSTER TRAUMA PUP PROGRAM .
c/o Richmond Fire Department Date Received :
6960 Gilbert Road
Richmond, 8.C. , ‘
V7C 3V4

Recorded By ;

Attention: Public Education Committee