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2. PAYMENT INFORMATION

   Alarm Registration Fee $78 

   Alarm Renewal Fee $51 

   Payments accepted by mail or in-person

4. Applicant Contact Information
6. First Name*
7. Last Name*
9. Location Address*
11. City*
12. State*
13. Zip*
15. Gate Code (if applicable)
17. Mailing Address
19. City
20. State
21. Zip
23. Home Phone*
24. Cell Phone
26. Business Phone
27. Email Address
31. Alarm Information
33. Alarm Company
34. Alarm Company Phone Number
36. License #
38. Address
40. City
41. State
42. Zip Code
44. Does alarm reset automatically?

    1. Yes
    2. No
45. After how long does the alarm reset?
46. Type of Alarm

    1. Audible
    2. Silent
48. Property Information
    Please indicate the location of any pets, guard dogs, firearms, ammunition, explosives, flammable liquids, poisonous materials or any other hazardous materials on the property to be protected by the security alarm system.
52. Additional Contacts
    All Applications Please Complete The Following:
    - Please indicate other persons who can be contacted, 24 hours a day, in case of an alarm.
    - Please list in order you wish individuals be contacted.
54. 1. Name
56. Address
58. City
59. State
60. Zip Code
62. Home Phone
63. Cell Phone
65. Business Phone
69. 2. Name
71. Address
73. City
74. State
75. Zip Code
77. Home Phone
78. Cell Phone
80. Business Phone
84. 3. Name
86. Address
88. City
89. State
90. Zip Code
92. Home Phone
93. Cell Phone
95. Business Phone
99. Electronic Signature Agreement*

    I hereby agree to maintain my alarm system in working order and abide by the stipulations as set forth in by the Municipal Code, Section 4-9.303
    
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
101. Electronic Signature
102. Date
     Date
107. 
     
Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit Submit and Print

* indicates a required field