Step 1.   Tell us a little about yourself

Your name:

Address 

City       State 

ZIP Code       Phone   

E-mail 

How did you hear about us? 

Step 2.  Tell us about your donation preferences

If there is a specific fire department that you would like to receive your endowment gift, please indicate the name of the department below.

What is the city and state the department is located in?

If your desired fire department is not available, what would you like us to do?

select another department for me contact me for another choice

Do you wish to remain anonymous?  no yes   

What would you like engraved on the nameplate affixed to the controller?

Max. 2 lines, 30 spaces per line:

LINE 1: 

LINE 2: 

Step 3.  Choose your payment method

If you are paying by check, print a copy of this page and send it with your check for $1500.00 payable to AUDIOTECH to:

Audiotech Digital Signal Corp., PO Box 167 / 951 Rice Road, Elma,  NY  14059

If paying by credit card (we accept MasterCard, VISA, or American Express), fill out the fields below and submit this form to us using the SUBMIT button.

Credit Card Type:  MasterCard VISA AMEX

Account #:

Exp. Date:  Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 01 02 03 04 05 06 07 08 09