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2. Date/Time
   Date/Time

   Date/Time
4. Do you live in the City of Fayetteville?*

   1. Yes
   2. No
5. Do you own or rent*

   1. Own
   2. Rent
7. Property Owner’s name if different from the applicant:
9. Number of levels in your home*
   -- Select One --12
10. Number of bedrooms in your home*
    -- Select One --1234
12. First Name*
13. Last Name*
15. Phone Number
16. Email Address
18. A Fayetteville Fire Department representative will contact you at the above number to set up a date and time for firefighters to come and install the smoke detector(s) in your home.
20. Street Number
21. Street Name
22. Street Type
23. Apt #
25. City
26. State
27. ZIP
29. Disclaimer:
    By submitting this application, I state that I currently reside in the residence. I also agree that I have requested that my residence be evaluated for installation of smoke alarms; replacement of existing outdated/inoperable smoke alarms; or the batteries. I agree; that I will allow City of Fayetteville Fire Department personnel or designated representative(s) to enter my residence for the purpose of a smoke alarm evaluation; installations of the smoke alarms/smoke alarm batteries; and to provide fire safety information and education to those present in the residence, and that I, my heirs and legal agents, do hereby release the City of Fayetteville employee(s), officer, agent, official or designated representative(s) from any and all liability for damages, injury or casualty of any sort whatsoever involving my residence, my property, myself or any other person, which results or may result from activities conducted from this installation.
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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