| PLEASE PRINT ALL INFORMATION |
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Name________________________________________________ |
Age______________ |
| Address______________________________ |
City_____________ |
Zip_______________ |
| County_______________ |
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| Telephone____________________________ |
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| If there is no phone, when could we
come by to install the detector?__________________ |
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_____________________________________________________________________ |
| Do you own________ |
Do you rent_______ |
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| Number of adults living
here_____________ |
Children_________ |
Physically Impaired__ |
| Number over age 62___________________ |
Number under age 6____________________ |
| Do you already have a working smoke
detector? Yes___________ |
No_______________ |
| Type of home: Single
story______________ |
Multiple story______ |
Apartment_________ |
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| This is an ionization type detector. |
Date
installed__________________________ |
| Number of detectors
installed______________ |
Tested: OK___________________________ |
| Station_______________ |
Shift____________ |
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| Statement: |
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I, __________________________________,
have agreed to the installation of this smoke detector and have
been given a brochure and/or instructions in its use. I understand
and agree that I will not hold the City of
__________________________ The ___________________ Fire
Department, Oklahoma SAFE KIDS Coalition, or the Oklahoma Office
of the State Fire Marshal, liable for any malfunction of the smoke
detector. |
| Signed_______________________________ |
Date______________________________ |
