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2. Hearing Impaired "Fire Safety Solutions" Smoke Alarm Application
4. Date of Application
   Date of Application
6. To participate in the program, you must:

   1. Answer all questions on this application;
   2. Be a resident of Oklahoma;
   3. Provide proof of your hearing loss (signature from a doctor, medical provider, audiologist, etc);
   4. NOT live in an institutional facility (dorm, nursing home, etc.)
8. Applicant Information
10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip Code
19. Phone Number
21. Email Address
23. Is email a good way to contact you?

    1. yes
    2. no
24. Date of Birth
26. Contact Person
    Please provide a Contact Person if you need assistance with scheduling the smoke alarm installation.
28. First Name
29. Last Name
31. Address
33. City
34. State
35. Zip Code
37. Phone Number
38. Email Address
40. Did the Contact Person assist you with this Application?

    1. yes
    2. no
42. Additional Information
    Please check the answer to the questions below. Your answers will tell us the type of equipment that best meets your needs.
44. 1. Type of Residence

    1. Single Family
    2. Multi Family
    3. Apartment
    4. Mobile Home
45. 2. Primary Disablity

    1. Deaf
    2. Hard of Hearing
46. 3. Primary Language

    1. English
    2. American Sign Language
    3. Other
48. Proof of Hearing Loss
    As proof of a disability - a professional may attest that you have a hearing loss with their signature above.
49. Proof of Hearing Loss
    Title of professional attesting the hearing loss
51. 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)
53. For Internal Use Only: Installer Assigned
54. Installer Name
Leave This Blank:


56. Submit Submit and Print

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