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* 1. Contact Information

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* 2. Do you currently have smoke detectors in your home? 

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* 3. How may bedrooms or sleeping areas are in your home?

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* 4. How may stories are in your home?

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* 5. Does your home have a basement?

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* 6. How many children (under 17) live in your home?

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* 7. How may adults?

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* 8. Which of the following actions would you like our firefighters to perform during their visit? Check all that apply.

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