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2. Name*

   First and Last Name

3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Date of Service*
14. Run Number*
16. Destination*
    -- Select One --Concord Hospital - Laconia

18. This application is to request to have the above customer's ambulance charges to be canceled. To apply, complete the questions below, attach the requested documentation, sign and return within 5 days.

    This application will be forwarded to the EMS Division for review and determination.

20. 
22. Your Family Size:*
23. Your Total Family Income:*
25. Please explain any unusual circumstances:*
27. IF YOU HAVE FINANCIAL ASSISTANCE FROM CONCORD HOSPITAL OR STATE OF NH FOOD STAMPS, PLEASE ATTACH AN APPROVAL LETTER.*

    1. Yes
    2. No
28. Upload

    Upload your financial assistance from Concord Hospital or State of NH Food Stamps here:

30. IF YOU DON'T HAVE FINANCIAL ASSISTANCE OR FOOD STAMP PAPERWORK, PLEASE ATTACH A COPY OF YOUR CURRENT FEDERAL TAX RETURN*

    1. Yes
    2. No
31. Upload

    Upload your current federal income tax ONLY if you do not have financial assistance from Concord Hospital or State of NH Food Stamps

33. 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.
35. Electronic Signature
36. Date
    Date
38. City of Laconia Fire Department

    848 North Main Street, Laconia, NH 03246

    Fax: 603-524-0437

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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