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I HEREBY CERTIFY that the statements made herein have been examined by me, and are, to the best of my knowledge and belief true and complete. Name (Must be signed by Owner, Partner, or Corporate Officer) Title Revised 12/10 North Pole Fire Department Pre-Fire Questionnaire The purpose of this questionnaire is to help us help you during an emergency. Please fill this form out as completely as possible. Please contact the Fire Department at 488-2232 if you need any assistance to complete thi.

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