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2. First Name*
3. Last Name*
5. Address*
   Please provide your physical address.
7. Address2
9. City*
   Applicant must reside in Gainesville city limits.
10. State*
11. Zip*
13. Telephone*
14. Alternate Telephone
16. Email Address*
18. Applicable Requirements*

    Applicant must meet one of the following requirements to receive a smoke alarm(s)/batteries. Please select all that apply.

    1. Reside in the city limits of Gainesville
    2. On fixed income
    3. Handicapped, or unable to install smoke alarm
20. Hold Harmless Clause
    The applicant hereby releases Gainesville Fire-Rescue and the City of Gainesville of any and all liability pertaining to the performance of the smoke alarm in the event the smoke alarm fails to perform property during a fire or any other conditions the smoke alarm was designed to operate in. The applicant also agrees to release Gainesville Fire-Rescue and City of Gainesville of any liability pertaining to damage that may result during the installation of the smoke alarm. The applicant will also allow Gainesville Fire-Rescue to install the smoke alarm and to inspect and perform and necessary maintenance at no charge to the applicant.
22. Agreement to Hold Harmless Clause*

    By checking this box, you agree to the above stated hold harmless clause.

    1. I agree.
24. Upon receipt of the application, Gainesville Fire-Rescue will contact you to schedule an in-home smoke alarm consultation.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field