Contact Information

First Name *
Last Name
Address
City
State *
Zip
Daytime Telephone *
Evening Telephone
E-mail Address*

AFCI Product Information at your installation

Select the Manufacturer/Brand Name of AFCI *
Select Amperage of AFCI
Select Poles of AFCI
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AFCI Installation Location

Date of Occurrence *

Date format must be: MM/DD/YYYY

Date of Installation

Date format must be: MM/DD/YYYY

Location
Address
City
State
Zip

Individual Reporting

Individual Reporting
Describe The Tripping Incident

What Equipment is Connected to the Circuit that is Tripping the AFCI?

Device Description *
Device Manufacturer Name
Device Model Number
Other Devices On The Circuit: (please describe)

Type of Residence/Room Affected

Please select residence type:
Please describe room(s) affected by trip
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