Smoke Alarm Request Form
Complete this form to request a no-cost smoke alarm with 10-year battery for your residence.  Requestors must be residents of Rostraver Township.  Qualifying homes can receive a combination smoke/carbon monoxide alarm.
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Name *
Installation Address *
Phone Number *
Email Address *
Do you own or rent your home? *
If you rent, please provide your landlord's name and contact phone number.  If you selected other, please explain.
How many livable floors are in your home, including the basement? *
How many bedrooms are in your home? *
Does your home currently have working smoke alarms? *
Does your home currently have working carbon monoxide alarms? *
What fuel(s) are used to heat your home? Please select all that apply. *
Required
Does your home have any appliances that are fueled by natural gas or propane?
Does your home have an attached garage where a vehicle can be stored? *
How many occupants live in your home? *
Are there any residents of your home under the age of 18? *
Are there any residents of your home with disabilities or special needs? *
If yes, please specify including ages and any limits to mobility.
Are any residents of your home deaf or hearing impaired? *
Does any resident of your home communicate primarily through American Sign Language (ASL)? *
How did you hear about the program?
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This form was created inside of Rostraver Township Fire Department.