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2. Date
6. Requestor Information
8. Fire Dept./Org.
9. FDID #
11. Contact
13. Phone
14. Email*
16. Street Address
18. City
19. County
20. Zip Code
22. Shipping Address
    If different from above.
24. Contact Name
26. Street Address
28. City
29. State
30. Zip Code
34. Order Information
36. How many smoke/CO combo alarms are you requesting?
37. How many smoke alarm brochures are you requesting?
41. Agreement

    By requesting smoke alarms through the Get Alarmed Kansas free smoke alarm installation program by the Kansas State Fire Marshal, I agree to the following (check each following statement)

    1. We will install smoke alarms at each location they are given away (and not hand them out to be installed by homeowners).
    2. We will educate the homeowners on smoke alarm maintenance and fire escape planning.
    3. We will submit the installation/liability forms to the OSFM after installation.
    4. We will install free smoke alarms for homeowners only and not landlords or businesses.
    5. Our organization agrees to the above terms in order to receive free smoke alarms through the OSFM Get Alarmed Kansas program.
43. By typing your name and date, you agree to each of the statements above.
45. Name
46. Date
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field