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2. Notice:

   You MUST be a resident of the City of Pontiac and own the property for which the alarms will be installed. Firefighters are required to install the alarms. As a requirement of the program, we cannot hand them out to you at the fire station.

4. First Name*
5. Last Name*
7. Address1*

   You MUST live within the city of Pontiac.

9. City*
10. State*
11. Zip*
13. Best Phone Number*

    This number will not be shared with any outside organization, it is only for us to be able to contact you to set up installation.

    
    

14. Do you own or rent your home?*

    1. Own
    2. Rent

    If you rent, we will follow up with your landlord/property management to get the required detectors installed in your home.

16. Do you have working smoke alarms in your home?*

    1. Yes, but they are expired/malfunctioning
    2. Yes, and they work
    3. No, I urgently need alarms!
17. Are your detectors hardwired?*
    -- Select One --Hardwired, with battery backupHardwired, no batteryBattery onlyI'm not sureI have NO alarms in my home

    If your home is equipped with interconnected alarms, we can’t remove/replace those. We can add alarms to replace expired/non-functional alarms, but they will not be interconnected.

19. How many bedrooms are in your home?*
    -- Select One --12345 or more

    Include rooms that are used for sleeping purposes only.

20. How many levels are in your home?*
    -- Select One --1234 or more

    Include the basement in this number, but not the attic unless it is an occupied floor with a bedroom, for example.

22. Do you have carbon monoxide (CO) alarms in your home?*
    -- Select One --Yes, but it's expired or malfunctioningYes, and it worksNo, but I need oneNo, I don't have any fuel-fired appliancesI'm not sure

    Any home with fuel-fired appliances such as gas stoves/ovens, gas furnaces, or gas dryers are required by law to have a CO alarm within 15 feet of every sleeping room.

23. Best time to contact you to install the alarms?*

    1. Morning
    2. Afternoon
    3. Evening
    4. No preference/Any time

    We will contact you to set up a convenient time for us to come install the alarms in your home.

25. Email Address

    What is the best email address we can use to contact you? If you do not have one, please leave blank.

27. Do you have any other questions or concerns?

29. * Indicates a required field

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field