Materials Order Form

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First Name*

Last Name*

Title*

Organization*

Mailing Address*

Check if this is a home address.

City*

State*

Zip Code*

Phone*

Email*

How many employees and volunteers in your organization:

What is the nature of your organization? (Check all that apply)

Other organization (please explain)

How will you use these safety materials? (check all that apply)

Other uses (please explain)

What do you feel are the most important safety topics that need to be covered in training materials?

How much do you agree with each of the following statements?

NW Natural is committed to the safety of first responders like me.

The information NW Natural provides is valuable for keeping first responders safe around natural gas.

I expect NW Natural to provide first responders the information necessary to get their jobs done safely around NW Natural natural gas infrastructure.

The first responders at my organization use NW Natural safety information to work more safely around natural gas.

The first responders materials provided by NW Natural help me and/or my coworkers perform their jobs more safely.

Internal Use Only

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Phone

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In case of emergency, call 911 and NW Natural at 800-882-3377.