Smoke Alarm Request
Name:
Address:
Phone:
Do you own or rent your home?
Pick One!
Own
Rent
If you rent, please provide Owner contact information:
What type of home?
Pick One!
Single Family Dwelling
Duplex
Apartment
Other
How many levels?
Pick One!
1
2
3
4
How many people:
Pick One!
1
2
3
4
Under the age of 5 live in your home?
Pick One!
1
2
3
4
Over the age of 65?
Pick One!
1
2
3
4
How many people in your home are disabled?
Pick One!
1
2
3
4
How many smokers live in the home?
Pick One!
1
2
3
4
Do you already have working smoke alarms in your home?
Yes
No
How did you find out about this program?
Pick One!
Door to door giveaway
Call to fire department
Newspaper or TV news
School
Display Booth
Other (specify)
If other, please specify