Darien Fire/EMS Department

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Walworth County

Township of Darien

Village of Darien

Smoke Alarm Request

Dear Resident:

The Darien Fire/EMS Department has initiated a Smoke Detector Program in our community. In order to obtain a smoke detector we ask that you meet the following criteria:

1. Live in the Village, or Town of Darien .
2. Be willing to let the Fire/EMS Department install the smoke detector.
3. Currently do not have a smoke detector in your home.

If you qualify, please complete this form.

Name

Address

Phone

Do you own or rent your home

If you rent please provide owner information

What type of home

How many people live in your home

Children under the age of 5 in your home

How many over the age of 65 live in your home

How many people in your home are disabled

How many smokers live in the home

Do you have smoke alarms

YES

NO

How did you find out about this program

If other please specify

Enter PIN

PIN

=

Enter the answer to the math problem to submit this form.

This helps prevent spam.

Darien Fire/EMS Department

602 Gerry Way

Darien, WI 53114

911

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