Smoke Alarms For Everyone

Installation or maintenance report and waiver of liability form.

Initial Application # *

Occupant Name *

# Smoke Alarms Installed *

None

# Carbon Monoxide Detectors Installed *

None

Was work performed on existing detectors? *

Yes

Detector Red Cross Serial #1

Detector Red Cross Serial #2

CES Run Number: (ie. 18-6000-123) *

# of Batteries Installed *

Type of Maintenance Performed *

Address Line 1

Address Line 2

Savannah *

Zip Code *

Occupant Email

Firefighter Name *

Truck Number *

Shift *

Date *

Is homeowner different than occupant? *

Yes

Homeowner Name *

Homeowner Address

Homeowner Address 2

Homeowner Zip

Homeowner City

Homeowner Phone

Occupant Signature

Reset Signature

Occupant Installation Acknowledgement

By signing above the occupant is accepting smoke alarm or CO Detector installation or maintenance from Chatham Emergency Services and acknowledges the release waiver below.

Occupant Installation Refusal

By signing above, the occupant acknowledges that Chatham Emergency Services has offered the installation or maintenance of smoke alarms or CO Detectors but at this time the occupant is refusing the offered service.

Firefighter Signature

Reset Signature