REQUEST FOR SMOKE ALARM INSTALLATION

Please complete the following information for a FREE Smoke Alarm Installation by trained Benton Co Fire District 2 personnel.

First Name (required)

Last Name (required)

Phone (required)

Email (required)

LOCATION INFORMATION

Address (required)

Street AddressCityState / Province / RegionZIP / Postal Code (required)

Do you own or rent your home? (required)

Type of Dwelling (required)

How many levels does your home have, including basement? (required)

How many bedrooms are in the home? (required)

What decade was your home built? (required)

SMOKE ALARM INFORMATION

Does your home currently have working smoke alarms? (required)

How many smoke alarms does your home currently have? (required)

How old are the smoke alarms? (required)

What type of smoke alarms? (required)

Is there a smoke alarm in EVERY bedroom in the home? (required)

Do you have a Carbon Monoxide alarm in your home? (required)

SPECIAL CONSIDERATIONS

Please indicate below if there are any special considerations we need to plan for when scheduling your visit.

If applicable, do you have a language barrier? If yes, what language do you use:

American Sign Language

Spanish

Other

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