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A non-profit 501(c)3 org


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Fire Safety House
Social Hall Rental
Request Home Safety Visit
Fire Extinguisher Training
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Home Fire Safety Visit Request Form

Please confirm whether you are the resident or you are applying on someone else’s behalf, in which case you will need to enter contact information for yourself and the occupier. All fields marked with an * are required.

Required   Indicates Required Field
Are you the resident?: Yes
Resident first name: Required
Resident last name: Required
Home address: Required
City: Required
Zip code: Required
Email address:
Is this address Owner-Occupied?: Required Yes
Is this address a Tennant-Occupied-Rental-Unit?: Required Yes
Is this address home to any pets(cats and dogs)?: Required Yes
Phone (day) Area code (###): Required
Phone (day): Required
Age of residence (yrs):
Phone (evening) Area code (###):
Phone (evening):
I prefer you contact me by: Phone
No Preference
Type of home (single family, apt, townhouse etc.): Required
Number of floors in home:
Number of working smoke alarms:
Senior citizen?: Required Yes
Children in the home?: Yes
Any special needs so we can customize our visit (examples: hearing impaired, low vision):
Do you have at least one working smoke alarm in your home?: Required Yes
Have you ever experienced a house fire?: Yes
How did you hear about this program?:
If you are filling this out on behalf of someone else, please provide your information:
Contact first name:
Contact last name:
Contact Phone Area code (###):
Contact phone:
Contact phone ext:
Contact email:
Prefered appointment times:
Additional information - please supply us with any additional information you would like us to be aware of:

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