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2. First Name*
3. Last Name*
5. Email Address*
7. Phone Number*
8. How many car seats?*
9. How many vehicles?*
11. Child's Age?*
13. Comments & Details about your Install/Check Request?
17. Schedule Options

    Please select up to four dates and time options below.  

    Please only select times after 4:00PM

    Please allow 48 to 72 hours for someone from our Department to respond to your request.

    If you should have any questions, please call Peters Township Fire Department at 724-941-4176

19. Date & Time Option #1? *
    Date & Time Option #1?

    Date & Time Option #1?

    After 4:00PM only

20. Date & Time Option #2?*
    Date & Time Option #2?

    Date & Time Option #2?

    After 4:00PM only

22. Date & Time Option #3?*
    Date & Time Option #3?

    Date & Time Option #3?

    After 4:00PM only

23. Date & Time Option #4?
    Date & Time Option #4?

    Date & Time Option #4?

    After 4:00PM only

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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