St. Mary Parish Fire Protection District #11

Smoke Detector Application / In Home Oxygen Registration

Smoke Detector Application
Name: *
Address: *
Home Phone:
 Cell Phone: *  
E-mail Address:
District (Sorrel, Four Corners, Louisa, or Glencoe.): *
Number of Adults in Residence:
 Number of Children in Residence:  
Number of Elderly in Residence (60 Years old and above):
 Alternate Contact Information
Name: *
Phone: *
E-mail Address (alt):

In Home Oxygen Registration

Name: *
 Phone: *  
 Address: *  
 Name of Company Delivering Oxygen: *  
 Delivery Location:  
Quantity of Oxygen in Residence: *
 Location of Stored Oxygen in Residence (Bedroom, Bedroom Closet, Hall Closet, etc.: *