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Hearing Impaired Form -Smoke Alarm Installation "Fire Safety Solutions" Smoke Alarm Application

  1. Hearing Impaired "Fire Safety Solutions" Smoke Alarm Application

  2. To participate in the program, you must:

  3. Applicant Information

  4. Is email a good way to contact you?

  5. Contact Person

    Please provide a Contact Person if you need assistance with scheduling the smoke alarm installation.

  6. Did the Contact Person assist you with this Application?

  7. Additional Information

    Please check the answer to the questions below. Your answers will tell us the type of equipment that best meets your needs.

  8. 1. Type of Residence

  9. 2. Primary Disablity

  10. 3. Primary Language

  11. As proof of a disability - a professional may attest that you have a hearing loss with their signature above.

  12. Title of professional attesting the hearing loss

  13. Mail, fax, or email this completed application to:

    Oklahoma ABLE Tech, c/o Smoke Alarm Application, 1514 Hall of Fame, Stillwater, OK 74078-2026 FAX: (405) 744-2487 EMail: abletech@okstate.edu Questions? Contact us at (405) 744-9748 (v/tty) or toll-free (888) 885-5588 (v/tty)

  14. For Internal Use Only: Installer Assigned

  15. Leave This Blank: