Office of the State Fire Marshal

Smoke Detector Installation Program
INFORMATION FORM

Name:
Date of Birth or Age:
Home Phone Number:	Day	Night
Work/Alternate Phone Number:	Day	Night
Preferred Contact Time:
Address of Residence:	City:	Zip:
Do you own and occupy this residence?:	Yes	No
Number of levels (floors), including the basement, at residence
Does the home have working smoke detectors:	Yes	No
Total number of occupants in residence:
Age(s) of occupant(s)*:
Any disabled adults(s)*: Yes No How Many Age(s): Any disabled child(ren)*: Yes No How Many Age(s): Any infirm (or extended illness) child or adult?*: Yes No How Many Age(s): Any hearing impaired?*: Yes No How Many Age(s):
* If over the age of 62 or "yes", name of individual(s): Does disability limit resident from changing smoke detector battery?  Yes No Additional Comments: