EMS Event Request
Event Name(*)
Event Start Date(*)
Event Start Time(*)
Event End Date(*)
Event End Time(*)
Event Address(*)
Event City(*)
Event State(*)
Event Zipcode(*)
Number of Attendees(*)
Event Description(*)
Event Contact Name(*)
Event Contact Number(*)
Event Contact - Day of Event(*)
Event Contact Cell Phone(*)
Event Contact Email(*)
Event Billing Contact(*)
Event Billing Address(*)
Event Billing City(*)
Event Billing State(*)
Event Billing Zipcode(*)
I understand that this is a request for service only and event coverage is not confirmed until I have received details from Guilford County EMS.
Do you acknowledge?(*)