FIRE SMART ASSESSMENT REQUEST FORM

Collection Notice
The information being collected will be used only for the purpose of completing FireSmart Home Assessments. The personal information you provide on this form is being collected under the authority of the Local Government Act. Your personal information is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act.

If you have any questions about the collection of this information, please contact the Information and Privacy Coordinator, 1975 Field Road, Sechelt, BC, V7Z 0A8, 604-885-6800.

* Full Name

* Address for assessment

Address

Country	Province/State

City	Postal/Zip Code

* Contact Phone Number

- -

* Prefer contact by email or phone?

Let us know if you prefer weekday or weekend, morning or afternoon, or a specific day of the week.

Approximate square footage of home on one level (i.e. the home's footprint)

Please provide any potential information a representative should know (aggressive dog, steep driveway, hard to find access, etc.)

Have you attempted to complete the self assessment here: https://firesmartbc.ca/resource-types/assessments/

What is your reason for requesting an onsite assessment?

* Please provide your consent for our representative to attend and perform an assessment when you are not home.