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FIRE DEPARTMENT
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Name:
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Address:
Phone Number:
Does the property owner live at this address?
Yes
No
Number of young children in this house:
Number of elderly in this house:
Number of disabled/special needs in this house:
Number of levels in the home (including basement):
1
2
3
Number of levels with sleeping areas/bedrooms:
1
2
3
Do you have a smoke detector in each level of the home?
Yes
No
Do you have a carbon monoxide detector in your home?
Yes
No
How did you learn about this program?
Flyer
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If other was selected above, please describe:
Services needed:
Smoke detector(s)
CO detector(s)
Detector batteries
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