Municipal Relations

S.A.F.E. Family Application Form

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General Information

Date of Request

Fire Department:

Mailing Address:

City/Town:

Postal Code:

Email Address:

Fire Chief Name:

Contact Name and Title:

Phone Number:

Alternate Phone Number (optional):

Number of Smoke Alarms Requested (max 48):

Please provide a brief summary outlining who will be responsible for the implementation of this program (community partners identified):

Start Date of Installations (all alarms must be installed within 6 months of the start date):

Area of Implementation (target area of highest need):

Advertisement (how will your community know about this program):