2. BARBERTON FIRE DEPARTMENT SMOKE DETECTOR PROGRAM
4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Ward
14. Phone #
15. Alternate Phone #
17. Current # of Detectors
18. Manufacture Date
20. Most convenient time to call & install

    1. Morning
    2. Afternoon
21. Are you a Senior Citizen (over age 60)

    1. Yes
    2. No
23. Are you a Single Head of Household

    1. Yes
    2. No
25. Physically Challenged person in home

    1. Yes
    2. No
26. If yes, please explain
28. How many floors in home?
29. Number of people in home?
30. Number of children under 18 in home?
32. Housing Status

    1. Single Family
    2. Multi Family
33. Ownership

    1. Rent Property
    2. Own Property
34. If Rental ... Land Lords Name, Address & Phone #
36. Permission Required*

    1. I agree to allow the City of Barberton or its representative to install the alarm in my residence in accordance with the manufacturer's recommendations.
38. Permission Required*

    1. I further agree to allow a representative of the Barberton Fire Department to conduct an informal home safety inspection.
40. In consideration of the goods/services provided by the Barberton Fire Department, I, on behalf of myself and other members of my household, do hereby release and agree to indemnify and hold harmless the City of Barberton Fire Department, and anyone acting as a representative of the City of Barberton, 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 in working condition, and the City of Barberton is not responsible for the maintenance of the alarm. You are being given one smoke detector by the City of Barberton Fire Department. It is recommended that a smoke detector is placed in each sleeping area and on each level of the home.
42. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
44. Signature:*
45. Date:*
47. This program is partially funded with Federal Funds. The following statistics are required for federal reporting purpose.
49. Race:*

    1. White
    2. Black/African American
    3. Asian
    4. American Indian/Alaskan Native
    5. Native Hawaiian/Other Pacific Islander
    6. Other
50. Income Level:*

    1. Less than $5,000
    2. $5,000 - $9,999
    3. $10,000 - $14,999
    4. $15,000 - $19,999
    5. $20,000 - $24,999
52. INSTALLER - COMPLETE BELOW:
    ___________ # BFD Alarms, Installed by #___________, Date: ______________________________________
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field