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2. Please enter your information and a representative of the Marietta Fire Department will contact you to schedule a Home Fire Safety Visit.
4. First Name
5. Last Name
7. Phone Number
8. Email
10. Street Address
12. Street Address Line 2
14. City
15. State
16. Zip Code
18. Type of Residence

    1. Single Family Home
    2. Condo / Townhome
    3. Apartment Building
19. Own or Rent Home?
    -- Select One --OwnRent
21. What areas of safety are you interested in learning more about?

    1. Smoke Alarms
    2. Fire Safety and Escape Plans
    3. Cooking Safety
    4. Child Safety
    5. Carbon Monoxide Information

    1. Electrical Safety
    2. Water Leak Emergencies
    3. Natural Gas Safety
    4. How and When to use 911
23. How did you learn about our program?*

    1. Friend/Colleague
    2. Fire Safety Education in School
    3. Website
    4. Blog/Message Board

    1. Facebook
    2. Instagram
    3. Billboard
    4. Print Mailing
Leave This Blank:


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