* indicates a required field

2. First Name*
3. Last Name*
5. Address*

   You must be a resident of the Village of Hanover Park.

6. Telephone Number*

   Your number will not be shared with any outside organizations.  It will only be used to contact you to set up installation.

7. Email Address*

   Your email address will not be shared with any outside organizations.  It will only be used for communication with the fire department for installation information.

9. How many levels are in your home?*

   Include the basement, but not the attic unless it is an occupied floor with a bedroom, for example.

10. How many bedrooms are in your home?*

    Include rooms that are used for sleeping purposes only.

11. Do you own or rent your home?*

    1. Own
    2. Rent

    If you rent, we will follow up with your landlord/property management to get the required alarms installed in your home.

13. Do you have working smoke alarms in your home?*

    1. Yes, but they are expired or malfunctioning
    2. Yes, and they work
    3. No, I urgently need alarms!
14. Is anyone in your household deaf or hard of hearing?

    1. Yes
    2. No
15. If yes, would you like information on a bed shaker alarm?

    1. Yes
    2. No
17. What is the best time to contact you to set up the installation?*

    1. Morning
    2. Afternoon
    3. Evening
    4. No preference/Any time

    We will contact you via telephone and email, within 3 business days, to set up a convenient time for us to come install the alarms in your home.

18. Do you have a preferred language for communication?

    We will do our best to accommodate your communication needs.

19. How Did You Hear About the Program?

    1. Weekly EBlast
    2. Highlighter
    3. Village Website
    4. Door Hanger
    5. Neighbor
    6. Other
21. Do you have any additional questions or concerns?
Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

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