SMOKE ALARM REQUEST

SMOKE ALARM REQUEST

CHOCTAW VOLUNTEER FIRE DEPARTMENT
NAME*
ADDRESS*
PHONE NUMBER*

HOME COMPOSITION*

	#
NUMBER OF ADULTS
NUMBER OF CHILDREN
NUMBER OF SENIOR CITIZENS

ARE THERE ANY DISABLED OCCUPANTS IN THE HOME?*

YESNO
DO YOU OWN OR RENT?*

OWNRENT
PROPERY MANAGER'S NAME*
PROPERTY MANAGER'S ADDRESS*
PROPERTY MANAGER'S PHONE NUMBER*
I release all agencies and their representatives from any and all liability, claims or actions that may arise from injury or harm to myself, my dependent(s) or damage to my property, in connection with the installation of this smoke alarm(s).

After installation, it shall be my responsibility, as the home/building owner and/or tenant, to maintain the smoke alarm(s), keeping it (them) in proper operating condition, which includes periodic testing and regular replacement of the unit(s) as recommended by the manufacturer.

I understand that the State of Louisiana, the Louisiana Office of State Fire Marshal, the installer and the local fire department are not responsible for proper operation of these smoke alarms.

With my signature below, I agree to the aforementioned statements and confirm the installation of smoke alarm(s) in my home/building by the fire department and their representative named above.
I AGREE TO THE FOREGOING*
SIGNATURE*

Clear
Should be Empty: