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2. First Name*
3. Last Name*
5. Coquitlam Address*
6. Postal Code
8. Email*
9. Phone*
11. Best time to contact you*

    1. Morning
    2. Afternoon
12. How many people live in the home?*
14. How many people over the age of 65 live in the home?*
15. How many children under 5 live in the home?*
17. Type of Home*

    1. Single family detached
    2. Townhome
    3. Basement suite
18. What year was your home built?*

    Estimated year is okay.

20. Do you have a working smoke alarm?*

    1. Yes
    2. No
22. How did you find out about the smoke alarm installation program?
    -- Select One --AdvertisingWebsiteSocial MediaFire Department Public Education EventOther
24. If Other, please specify
26. Freedom of Information and Protection of Privacy Act*

    By checking this box, you are consenting to the collection, storage, use and disclosure of your personal information. The City has authority to collect, use and disclosure your information for the purposes of the City’s Smoke Alarm Program in accordance with Section 26(c) of the Freedom of Information and Protection of Privacy Act. Should you have any questions or concerns about the collection of your personal information please contact Bob Hieltjes, Assistant Chief Fire Prevention, by email.

    1. I consent
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field