Town of Kimball- Information Collection Form

Town of Kimball- Information Collection Form

* indicates required

Email Address *

First Name *

Last Name *

Address *

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Phone Number What is your home phone number

Do you live in the Kimball Fire Response Area *

Mailing Address

Address Line 2

City

State/Province/Region

Postal / Zip Code

Country

Please check the services you use ( check

Trash Pickup
Fire Fee
Both

Physical Zip

Cell Phone Number

Please select your cell phone carrier

AT&T
T-Mobile
Verizon
Other (see below)

Carrier Name( if not listed)