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2. Name*
3. Phone Number*
4. Email Address*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Do you rent the residence?*
    -- Select One --yesno
14. How many total sleeping areas/bedrooms do you have?*
    -- Select One --12345+
16. Release and Hold Harmless Agreement

    By submitting this form, you give permission to the Olive Branch Fire Department to place a battery-operated smoke alarm(s) in your home.  This device (and replacement batteries when available) is furnished from a Smoke Alarm Fund with contributions from the Mississippi State Fire Marshals Office. You understand that the City of Olive Branch does not warrant the manufacture's guarantee/ Should the alarm fail to operate in the event of a fire, the City of Olive Branch shall not be liable for any claims associated with that fire and/or the failure of the device. You also understand that neither the City of Olive Branch nor its Fire Department are not responsible for maintaining the device and replacing the battery each year at the same time (or when the device "chirps" indicating that the battery is worn-out). Please request that a new battery be installed if you are unable to do it yourself.  If batteries are available from the Mississippi State Fire Marshals Office, we will install replacements each year when requested. I have read and agreed to the above terms. 

18. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.

    1. I do not agree
20. Electronic Signature
21. Date*
    Date

23. If you any questions regarding this form, feel free to call the Fire Administration at 662-892-9550. If you know of a family member, friend, or neighbor who does not have at least one smoke detector in the home, simply ask them to complete this form as well.  

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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field