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Smoke Detector Application

  2. Most convenient time to call & install
  3. Are you a Senior Citizen (over age 60)
  4. Are you a Single Head of Household
  5. Physically Challenged person in home
  6. Housing Status
  7. Ownership
  8. Permission Required*
  9. Permission Required*
  10. 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.
  11. 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.
  12. This program is partially funded with Federal Funds. The following statistics are required for federal reporting purpose.
  13. Race:*
  14. Income Level:*
    ___________ # BFD Alarms, Installed by #___________, Date: ______________________________________
  16. Leave This Blank:

  17. This field is not part of the form submission.