The City of Stamford, CT - ALARM REGISTRATION

ALARM REGISTRATION FORM

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PART I: ALARM USER INFORMATION
Required fields are marked with an *

* Type of alarm System (check all that apply) :

Burglary

Hold-Up / Panic

Fire

Medical

Other

If Type is Other, Please Specify :

* Alarm Address : (street of alarm location)
House Number :
Apartment Number :
Zip Code at Alarm Address :

* This location is: Commercial Residential

* Phone at Alarm Location:

Daytime Phone of Alarm User (If Different):

* Last Name or Business Name:

First Name (for Residential Alarms Only):

Person Responsible for Security ( First and Last Name - Business Alarms Only):

Is the mailing address the same as the alarm address?		Yes, use the same address
Is the mailing address the same as the alarm address?		No, use the address that I enter below.

Street

City

State, Zip

PART II: MONITORING AND INSTALLATION INFORMATION

Name of Alarm Installer:

Phone (Including Area Code):

Address Of Alarm Installer:
Street
City
State, Zip

Is the Alarm Monitored? (choose Yes or No): Yes No

If you answered "Yes" to the above question (Is Alarm Monitored?), please provide the following:

Name of Alarm Monitor:

Address Of Alarm Monitor:
Street
City
State, Zip
Phone	(Including Area Code)
24-Hour Phone (if Different)	(Including Area Code)

PART III: EMERGENCY CONTACT INFORMATION

Please designate a "Keyholder" or other responsible party who can assist emergency personnel if the Alarm Owner is not available.

Name of Keyholder:

Address Of Keyholder:
Street
City
State, Zip
Phone	(Including Area Code)

I verify that all the above information is true and correct to the best of my knowledge.

* Your Name:
* Your Phone:
Your E-mail:

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