Customer's Information

Customer's First Name

Customer's Last Name

Customer's Email *

Customer's Phone *

Provincial Tax *

Address

Street Address

City

State

Country

Postal code

New Affiliate Information

Affiliate's First Name

Affiliate's Last Name

Affiliate's Email

Affiliate's Phone

Referrer's Information

Referrer's First Name *

Referrer's Last Name

Referrer's Email *

Referrer's Phone Number *

Safety Advisor's Information

Safety Advisor's First Name *

Safety Advisor's Last Name *

Safety Advisor's Email Address *

Safety Advisor's Phone *

Second Safety Advisor First Name (Optional)

Second Safety Advisor Last Name (Optional)

Second SA Email Address (Optional)

Second SA Phone 2 (Optional)

Order information

Number of Smoke Sensors *

Number of Heat Sensors *

Number of CO Sensors *

Number of Mattress Shakers *

Number of Comm Link *

Number of Water Sensors

Number of Fire Blanket

Only add value if it is an additional order on top of the free sensors (Put "0" zero if it's "none")

Number of Fire Extinguisher

Only add value if it is an additional order on top of the free sensors (Put "0" zero if it's "none")

Total Purchase Price

Total Taxes

Total Purchase Amount Due

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