Lompoc Fire Department

Please print, complete, and mail this form to the address below with payment.

Wendy Ofenloch - OSA IV
Lompoc Fire Department
115 South G Street
Lompoc, CA 93436

Shoulder Patch Order Form

Contact information:

NAME: ________________________________________________________

ADDRESS: _____________________________________________________

CITY:____________________________ STATE:_____ ZIPCODE: __________

PHONE: (_____)________________________________

E-MAIL: _____________________________________

 

Order Information:

NOTE: Make all payments payable to: CITY OF LOMPOC

QUANTITY of PATCHES: 1 X $5.00 (US) = $5.00 (US) TOTAL (Limit One)

ENCLOSED IS A: ___Personal Check ___Money Order

SHIP TO: (Leave the below items blank if same as information above.)

NAME: ________________________________________________________

ADDRESS: _____________________________________________________

CITY:____________________________ STATE: ____ ZIPCODE: __________

PHONE : (_____)________________________

E-MAIL: _____________________________________