FIRST NAME LAST NAME STREET ADDRESS CITY STATE / ZIP CONTACT PHONE# CONTACT E-MAIL DO YOU CURRENTLY RENT OR OWN? DO YOU CURRENTLY HAVE SMOKE DETECTORS IN YOUR HOME? YES NO IF YES: How many hardwired? IF YES: How many battery powered? WHAT IS THE ESTIMATED AGE OF YOUR DETECTORS? --------------------------- 1-2 YEARS 3-5 YEARS 5-10 YEARS OVER 10 YEARS ARE ALL YOUR DETECTORS OPERATIONAL? Yes No Unknown WOULD YOU LIKE US TO INSPECT YOUR DETECTORS? Yes No DO YOU REQUIRE NEW DETECTORS TO BE INSTALLED? Yes No Unknown COMMENTS OR QUESTIONS