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2. Please read before completing form:

   If your home has smoke alarms that are hard-wired, we will be unable to provide you with our battery-operated smoke alarms. Please contact an electrician or your alarm company for assistance.

3. First Name*
4. Last Name*
6. Address*
8. City
9. State
10. ZIP Code
12. Year Home Built
14. Levels in Home*
16. Number of Bedrooms*
17. Height of Ceilings over 9 Foot?
    -- Select One --YesNo
19. Phone Number*

21. Please note that if your request is submitted outside of normal business hours Monday - Friday, on the weekend, or on a holiday, the request will be processed on the following business day.

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

    This field is not part of the form submission.

24. Submit

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