Sunday September 7, 2008

NAME:__________________________________ PHONE NO._______________________

NAME:__________________________________ PHONE NO._______________________

NAME:__________________________________ PHONE NO._______________________

NAME:__________________________________ PHONE NO._______________________

Return application with Check to:

Rural Security Fire Company
Attn: Rick Mease
1301 North Seventh Street
Lebanon, PA 17046

All checks are to be made payable to Rural Security Fire Company