2. Do you live within the unincorporated areas of Clay, German, Harris Township, Roseland and Indian Village?*

   1. Yes (live within the Clay Fire Territory)
   2. No (live outside the Clay Fire Territory)
4. Requesting:

   1. Smoke Alarm Installation
   2. Carbon Monoxide Detector (If available)
6. First Name*
7. Last Name*
9. Address1*
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address
18. Do you own or rent your home?

    1. Own
    2. Rent
20. How many floors to your home (include basement)?*
21. How many bed rooms?*
23. Are your smoke alarms hardwired?
    -- Select One --NoYesNA
25. Clay Fire will supply battery operated Smoke Alarms only not hardwired Smoke Alarms. Questions please contact the Community Risk Reduction Division for more information.
27. When is a good time to contact you?*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field