For Fire or Emergency Dial 781-9200
For General Information Dial 409-4700

URGENT SUBMISSION REQUESTED!

HOME SURVEY FORM
In order to assist us better in the event we are needed to respond to
your home please fill out and submit the survey form below.

ALL SUBMITTED INFORMATION IS CONSIDERED
CONFIDENTIAL AND WILL BE FOR THE SOLE USE OF THE
NORTH BELLMORE VOLUNTEER FIRE DEPARTMENT

ADDRESS:
(house # - street - city)
OCCUPANT
NAME :		  
NEAREST
CROSS STREET:
LIST ANY DISABLED OCCUPANTS AND
THEIR LOCATION:
NUMBER OF STORIES & HOUSE STYLE:
(cape, ranch, split,etc.)
NUMBER OF PERSONS
SLEEPING ON EACH STORY: 		Basement

First Floor

Second Floor

Third Floor

Other
GAS SERVICE:
(meter location)
ELECTRIC SERVICE:
(meter location)
WATER SERVICE:
(meter location)
OIL TANK LOCATION:
   

LIST LOCATION & AMOUNT OF FLAMMABLE LIQUIDS and/or HAZARDOUS MATERIALS IN THE SPACE BELOW (include oxygen and/or other compressed gases):

FIRE ALARM SYSTEM:
IF YES, IS IT CONNECTED TO A CENTRAL STATION:
IF YES, PROVIDE NAME & PHONE OF CENTRAL STATION IN THE SPACE BELOW:

PLEASE PROVIDE LOCATION OF FIRE ALARM PANEL IN THE SPACE BELOW:

PLEASE LIST EMERGENCY CONTACT NAME & NUMBER IN THE SPACE BELOW:

 
ENTER ANY ADDITIONAL INFO / COMMENTS IN THE SPACE BELOW:
   

YOUR ASSISTANCE WITH PROVIDING THE NORTH BELLMORE VOLUNTEER FIRE DEPARTMENT WITH THE ABOVE INFORMATION IS GREATLY APPRECIATED!