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Emergency Evacuation Assistance Form

The information submitted in this form is intended to assist emergency response teams in the event of an evacuation or during emergency measures. It is kept confidential and used solely by the emergency and fire protection services of Pincourt and Notre-Dame-de-l’Île-Perrot.

Identification du réclamant
Nom
Téléphone principal 
Téléphone secondaire

(ex. : rez-de-chaussée, sous-sol, 1er étage...)

Informations sur votre situation
Sélectionnez parmi les situations suivantes : 
Renseignements sur la personne-ressource
Nom
Téléphone principal 
Téléphone secondaire
Consentement 
Consentement