Fire Department Smoke/CO Signups

CITY OF AKRON

FIRE DEPARTMENT
THE DEPARTMENT OF PUBLIC SAFETY DIVISION OF FIRE

Fire Prevention Bureau 81 W. Thornton St 330-375-2197 or 330-375-2211
Please complete this form if you need smoke detectors

Carbon Monoxide form is below
SMOKE DETECTOR FORM
Name
Address
Zip Code
Phone Number

Area CodePhone Number
Current # of alarms
Age of Alarms
Smoke Alarms work?

YesNo
Co Detectors

YesNo
Are you over the age of 65?

YesNo
Any Physical Impairments in the home?

YesNo
# of Occupants in home
# Of Children under 18 in the home
Housing Type

Single Family HomeMulti-Family Home
# of bedrooms
Do you own or rent?

OwnRent
Reside at this residence

YesNo
I agree to allow the City of Akron or it's representatives to install the alarm(s) in my residence, in accordance with the manufacturer's recommendations. / further agree to allow a representative of the Akron Fire Department to conduct an informal home safety inspection. In consideration of the goods/services provided by the Akron Fire Department, I, On behalf of myself and the their members of my household, do hereby release and agree to indemnify and hold harmless the City of Akron Fire Department, and anyone acting as a representative of the Cit of Akron, from any liability in connection with the goods/services provided. I understand if an alarm is provided, it is my responsibility to maintain the alarm(s) in working condition, and the City of Akron is not responsible for the maintenance of the alarm(s)
Signature

Clear
Date

MonthDayYear
Date
Carbon Monoxide Detector Form

*If you need Carbon Monoxide Detectors*
Name
Address
Zip Code
Phone

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Current # of alarms
Manufacturers date

MonthDayYear
Date
# of Occupants in home
# Of Children 18 in the home
Are you over the age of 65?

YesNo
Any Physically Impairments in the home?

YesNo
Housing Type

Single Family HomeMulti-family Home
# of Floors in the home
# of bedrooms
Do you own or rent

OwnRent
Total Household Income

Under $60,000Over $60,000
I agree to allow the City of Akron or it's representatives to install the alarm(s) in my residence, in accordance with the manufacturer's recommendations. / further agree to allow a representative of the Akron Fire Department to conduct an informal home safety inspection. In consideration of the goods/services provided by the Akron Fire Department, I, On behalf of myself and the their members of my household, do hereby release and agree to indemnify and hold harmless the City of Akron Fire Department, and anyone acting as a representative of the Cit of Akron, from any liability in connection with the goods/services provided. / understand if an alarm is provided, it is my responsibility to maintain the alarm(s) in working condition, and the City of Akron is not responsible for the maintenance of the alarm(s)
Signature

Clear
Date

MonthDayYear
Date
I have reviewed the previous form about Carbon Monoxide safety*

Yes
Should be Empty:

CITY OF AKRON

THE DEPARTMENT OF PUBLIC SAFETY DIVISION OF FIRE

Please complete this form if you need smoke detectors