VAN BUREN FIRE DEPARTMENT SMOKE DETECTOR INSTALLATION PROGRAM

APPLICATION

Please read and complete BOTH SIDES of this application. This application and waiver must be completed and SIGNED before approval and installation of smoke detector(s).

NAME:                                                                                             DATE:                                     

ADDRESS:                                                                                                                                     

                 VAN BUREN TOWNSHIP, MI 48111       

HOME PHONE:                                                  DAYTIME PHONE:                                                  

AGE OF HOMEOWNERS:  MALE:                            FEMALE:                         

IS YOUR HOUSEHOLD INCOME BELOW $25,000   YES               NO                                                  

ARE THERE ANY EXISTING SMOKE DETECTORS IN YOUR HOME?                       

HOW MANY STORIES DOES YOUR HOME HAVE?                       

DO YOU HAVE A BASEMENT?                       

HOW DID YOU HEAR ABOUT THIS PROGRAM?                                                                               

The Van Buren Fire Department will contact you upon acceptance of this application to arrange a date and time for installation. We will be able to schedule installations on certain weekdays, evenings, and weekends. Any emergency calls received will take precedence and may delay a scheduled installation. Your flexibility will be greatly appreciated.

SIGNATURE:                                                      PRINT NAME:                                                        

ADDRESS:                                                                                                                                     

                      VAN BUREN TOWNSHIP, MI 48111     

Please Return Application To: Chief Mark Nicholai

                                                    Van Buren Fire Department

                                                    46425 Tyler Road

                                                    Van Buren Township, MI 48111 

(FOR OFFICE USE ONLY)

Station#                                    Date Installed:                                    Installed By:                               

Appointment Time:                                           Number of Detectors Installed: