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2. First Name*
3. Last Name*
5. Phone Number*
7. Address1*
9. City
10. State
11. Zip
13. Resident of Clayton*

    1. Yes
    2. No
14. How many smoke detectors are you requesting?*
16. Reply email address
18. How many people live at the above residence?*
19. How many youths aged 17 and under live at the above residence?*
20. How many adults aged 65 and older live at the above residence?*
22. How many individuals with a disability, or an access or functional need live here?*
23. How many veterans, military members, or military family members live here?*
25. How many pre-existing smoke alarms does the household already have?*
26. How many pre-existing smoke alarms are working?*
27. Preferred Install Times*
29. Do you have battery or hardwired detectors

    a. NOTE:  If you have hardwire: the Clayton Fire Department does not provide hardwired detectors, they must be purchased prior to install. We can provide an assessment to the residence on what type needs to be purchased.

    b: Do we want to add batteries must be provided prior to battery charge? Again, we can provide an assessment with what battery types to buy beforehand. The Clayton Fire Departmen carries some batteries, but do not provide a huge amount of these.

31. FOR INTERNAL USE ONLY
32. Number of smoke detectors installed
33. Installer Name
34. Date Installed
36. Installers Signature
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field