2. 
3. Kinston Department of Fire and Rescue
   P. O. Drawer 339, 401 E Vernon Avenue Kinston, North Carolina 28502 Office Phone: 252-939-3164 Fax Phone : 252-939-3157
5. Private Residence Fire Safety Check Request Form
7. Requester Information
8. Date of Request*
   Date of Request
10. Name of Requester:*
11. Middle Name:
12. Last Name:*
14. Address:*
16. City:*
17. State:*
18. Zip Code:*
20. Contact Phone Number:*
21. Email Address*
23. Private Residence Request Information
25. Date Available for Inspection:*
    -- Select One --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
26. Day:*
    -- Select One --01020304050607080910111213141516171819202122232425262728293031
27. Year:*
    -- Select One --2017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047
29. Time Available for Inspection:
    -- Select One --8:00 AM9:00 AM10:00 AM11:00 AM12:00 PM1:00 PM2:00 PM3:00 PM4:00 PM5:00 PM6:00 PM7:00 PMOther
30. If Other is selected please list Time Requested:
32. Waiver of Hold Harmless and Release:
    THIS RELEASE, made and entered into this the by and between the UNDERSIGNED, hereinafter referred to as HOMEOWNER; (Whether actual Owner or Occupant only) and the City of Kinston, a municipal corporation of the State of North Carolina, herein after referred to as the “CITY.” W I T N E S S E T H WHEREAS, The CITY through its Department of Fire and Rescue personnel has offered, at no cost, to visit the homes of its citizens and make fire safety audits and recommendations and install fire alarms and portable smoke detection devices purchased previously by the HOMEOWNERS and as a service to the citizens of Kinston: NOW, THEREFORE, as an inducement for and in consideration of the services rendered by the City of Kinston Department of Fire and Rescue in conducting safety audits, making recommendations and installing fire alarms and smoke detection devices purchased by the HOMEOWNERS, and for other good and valuable consideration received, the Homeowner, for themselves, their heirs, executors, administrators and assigns, hereby release, acquit and forever discharge the CITY, its agents, employees, representatives and any and all other persons, associations, and other legal entities associated with or in any manner or fashion whatsoever connected with the CITY from any and all actions, causes of action, claims, demands, damages, known or unknown, now existing or which may hereafter arise, by reason of personal injury and/or property damage, in any way connected with or arising out of the location of, installation of, operation, maintenance or failure of the unit installed. The Homeowners hereby assume any and all liability arising in any manner whatever for such personal injury and property damage, as is set forth above, to any non-party to this Release, including but not limited to guests, invitees, licensees, and residents at the address set forth below, whether or not such persons are competent or minors. The HOMEOWNERS agree to indemnify and hold the CITY harmless from such actions or proceedings, as described above, as may be brought by such non-parties. The HOMEOWNERS further agree that they will take no action and will permit no other person to take any action which will in any manner damage or impair the operation of the aforesaid portable smoke detection device. Further, the HOMEOWNERS agree to take any and all action necessary to maintain the aforesaid portable smoke detection devices and the inspection thereof, may be modified or terminated at any time by the CITY with notice to the Homeowners. The HOMEOWNERS state that they have carefully read the foregoing Release and know and understand the contents thereof, and acknowledge that there are no terms or conditions of this Release except as set forth herein, and sign the same as their own voluntary and free act and terms hereof are contractual and not a mere recital, and acknowledge that they have been given a copy of this Release.
34. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature*
38. Date and time of the Waiver of Hold Harmless and Release:*
    Date and time of the Waiver of Hold Harmless and Release:

    Date and time of the Waiver of Hold Harmless and Release:
    This Waiver of Hold Harmless and Release has been read, agreed to, and electronically signed by me at this day and time.
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

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