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2. First Name*
3. Last Name*
5. Street Address*
7. City*
8. State
9. Zip Code
11. Phone Number*
12. Email Address
16. Please read carefully and answer or check the corresponding questions.
18. I hereby make application to be furnished with fire protection by the Fire Department of the City of Litchfield, Illinois on the following described premises, to-wit: *
20. The above described premises consist of: *
22. I hereby represent that I am the owner of the above described premises, and such representation is made for the purpose of having this application accepted by the City of Litchfield. *

    1. Yes
24. I hereby agree to pay the annual fee set forth by the city, and it is understood that the protection becomes effective upon payment of said fee and acceptance of this application.*

    1. Yes
26. In addition to the annual fee set forth above, I hereby agree to pay the City of Litchfield for each time the firefighting equipment of the City is called to said premises a flat rate of $500.*

    1. Yes
28. It is understood that all fire calls in the City of Litchfield will take priority over any call issued by me, and if a fire call should originate in the said City during the time that said fire equipment is engaged at or en route to the above premises for the purpose of fighting a fire on said premises, said fire equipment may return immediately to the City of Litchfield.*

    1. Yes
30. It is further understood that the service to be rendered under this agreement contemplates the furnishing of one unit of firefighting equipment, adequately manned, only, provided, however, that if the force on duty at the fire station in the City will permit, and additional man or men will be furnished without extra charge.*

    1. Yes
32. It is further understood that only such property will be extended fire protection as the person of City equipment believes to be feasible and practical, and a determination by the person in charge of firefighting equipment, that any requested action is hazardous, shall be final conclusive.*

    1. Yes
34. It is further understood that the City of Litchfield undertakes no responsibility for personal or property damage, whether caused by the negligence of its officers or employees, or from any unforeseen happening or event, and I hereby expressly release and discharge the City of Litchfield, its officer and employees from any and all liability or responsibility in any way arising from its activities in pursuance of this agreement.*

    1. Yes
36. It is further understood that the applicant may be required to furnish a sketch locating applicant's premise in relation to the Litchfield Fire Department, designating thereon the most direct and safest route from said department to the premises of the applicant with a designation of all bridges on said route. The Fire Chief shall inspect the designated route and his recommendation submitted to the Council. All premises covered in accordance with the terms of this application shall be open to inspection by the fire marshal of the City and the rules and regulations of the Litchfield Fire Department shall equally apply to applicant's premises.*

    1. Yes
38. It is further understood that the protection herein applied for, when accepted by the City, may continue during succeeding years, provided the required annual fee is paid on or before the end of the preceding year, and the payment of such annual fee carries with it the obligation to pay, in case of fire, the other charges herein enumerated. However, nothing herein contained shall bind the City to continue fire protection beyond each annual period paid for by the applicant.*

    1. Yes
40. This agreement shall be subject to final approval of the Council of the City of Litchfield, Illinois.
42. Dated this day:*
    Dated this day:
44. Fee
    Sign Up Fee
45. Price
46. Quantity
47. Shipping Cost
49. Taxable
51. Applicant Signature*
    Please type full name.
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