Fire Safety and Evacuation Plan - Resident Signature
Instructions: Fill out form. Items in red boxes are required.
FACILITY NAME
FACILITY ADDRESS
Names of All Adult Residents:
Building Address and Apartment Number
Move In Date
I/We, the above named residents, certify that we have received, read, and fully understand the Fire Safety and
Evacuation Plan and agree to adhere to the detailed information outlined within the document.
Adult Resident Signature and Date
Adult Resident Signature and Date
Adult Resident Signature and Date
Adult Resident Signature and Date
Facility Manager or Authorized Agent Signature and Date