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2. Name*

   This is the name of the person needing the change

4. Email*

   This is the email for the person needing the change

6. Are we adding to or deleting from the system?*

   1. Add
   2. Delete
7. Which station are you a member of?*

   1. Blue Ridge
   2. Troutville
   3. Buchanan
   4. Fincastle
   5. Eagle Rock
   6. Glen Wilton
   7. Read Mountain
   8. County Staff
9. Are you a new user or existing somewhere else?*

   1. New
   2. Existing somewhere else
11. If you exist somewhere else, what is their device code?
13. Cell Phone Number*
15. iPhone or Android?*

    1. iPhone
    2. Andriod
17. Who is requesting this change?*

    Name of the person requesting this change

19. After submittal, Botetourt Fire & EMS administration will check with the officers of the station for approval to the system. You will be notified after the approval has processed.
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field