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2. 

   P.O. Box 199 Clinton, NC 28329
3. Smoke Alarm Request
5. In an effort to provide you with the most effective services possible, we would like to find out a little more about you, your household and the level of awareness for fire safety that exists within your home.
7. Name
9. Address
10. City
11. State, Zip Code
13. Have Smoke Alarms?

    1. YES
    2. NO
14. In date?

    1. YES
    2. NO
15. Are you a Landlord?

    1. YES
    2. NO
16. Do you Rent ?*

    1. YES
    2. NO
18. 1. Do you have a fire escape plan within your home ?

    1. YES
    2. NO
19. 2. Do you have a working in-date fire extinguisher in your home?

    1. YES
    2. NO
    3. UNKNOWN
20. 3. Have you been shown how to use a fire extinguisher?

    1. YES
    2. NO
21. 4. Do you conduct safety drills?

    1. YES
    2. NO
23. 5. Would you like to recieve additional information for fire safety?

    1. YES
    2. NO
24. 6. How Many people live in your home?
26. Additional Information
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field