Form EA121212 "Alarm System Registration & Renewal Form" - City of Bethlehem, Pennsylvania

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CITY OF BETHLEHEM ALARM SYSTEM REGISTRATION & RENEWAL
#________________
CHECK ONE OF THE BELOW:
Permit
REGISTRATION: [ ] BUSINESS ALARM -
FILING FEE $50.00
RENEWAL: [ ] BUSINESS ALARM– (NO FEE)
--
[ ] RESIDENTIAL ALARM - FILING FEE $25.00
[ ] RESIDENTIAL ALARM - (NO FEE)
Name of Occupant or Business: _________________________________________________________________________________________________
Full Address: _______________________________________________________________________________________________________________
Telephone: _____________________ Cell Phone: ______________________Email Address: _______________________________________________
Occupant or Business Mailing Address (if different from above): ______________________________________________________________________
Full address: ________________________________________________________________________________________________________________
Telephone: _______________________Cell Phone: _______________________ Email Address: ___________________________________________
Alarm Type: Burglar
Fire Hold-Up
Medical Emergency
Panic
Other __________________________
[ ]
[ ]
[ ]
Type of Dwelling:
Business/Commercial
Student Apartments
Single Residence [ ] Multiple Dwelling
Communications Type: Central Station Local Sounding Only (Audible Alarm Must Shut Off In 10 Minutes) Silent
NOTIFICATION LIST (Minimum of 2)
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Special Information: (Guard on Site, Dogs in Building, Hazardous Materials, etc.) __________________________________________________________
Alarm Company: ___________________________________________ Address: __________________________________________________________
City: _________________________ State: _______________Zip: _____________________Telephone: _______________________________________
Signing this form acknowledges that the above information is correct and that it may only be given to the authority having jurisdiction.
Subscriber: __________________________________________
Alarm Company: ___________________________________Date:
CHECK OR MONEY ORDER, MADE PAYABLE TO THE CITY OF BETHLEHEM.
MAIL TO: CITY OF BETHLEHEM ALARM ADMINISTRATOR, 10 EAST CHURCH ST, BETHLEHEM, PA 18018
CALL CRIME PREVENTION (610-865-7181) WITH QUESTIONS
ST
NOTE: THERE IS A $25.00 PENALTY FOR FAILING TO RENEW THE REGISTRATION AFTER JANUARY 31
OF EACH YEAR
Form EA121212
CITY OF BETHLEHEM ALARM SYSTEM REGISTRATION & RENEWAL
#________________
CHECK ONE OF THE BELOW:
Permit
REGISTRATION: [ ] BUSINESS ALARM -
FILING FEE $50.00
RENEWAL: [ ] BUSINESS ALARM– (NO FEE)
--
[ ] RESIDENTIAL ALARM - FILING FEE $25.00
[ ] RESIDENTIAL ALARM - (NO FEE)
Name of Occupant or Business: _________________________________________________________________________________________________
Full Address: _______________________________________________________________________________________________________________
Telephone: _____________________ Cell Phone: ______________________Email Address: _______________________________________________
Occupant or Business Mailing Address (if different from above): ______________________________________________________________________
Full address: ________________________________________________________________________________________________________________
Telephone: _______________________Cell Phone: _______________________ Email Address: ___________________________________________
Alarm Type: Burglar
Fire Hold-Up
Medical Emergency
Panic
Other __________________________
[ ]
[ ]
[ ]
Type of Dwelling:
Business/Commercial
Student Apartments
Single Residence [ ] Multiple Dwelling
Communications Type: Central Station Local Sounding Only (Audible Alarm Must Shut Off In 10 Minutes) Silent
NOTIFICATION LIST (Minimum of 2)
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Person: ________________________________________ ADDRESS: __________________________________________________________________
Home Phone: _____________________________
Work Phone: __________________________
Cell, Pager, Other: ________________________
[ ] YES
[ ]
Title/Relationship: ________________________________________ Has Keys:
NO
Special Information: (Guard on Site, Dogs in Building, Hazardous Materials, etc.) __________________________________________________________
Alarm Company: ___________________________________________ Address: __________________________________________________________
City: _________________________ State: _______________Zip: _____________________Telephone: _______________________________________
Signing this form acknowledges that the above information is correct and that it may only be given to the authority having jurisdiction.
Subscriber: __________________________________________
Alarm Company: ___________________________________Date:
CHECK OR MONEY ORDER, MADE PAYABLE TO THE CITY OF BETHLEHEM.
MAIL TO: CITY OF BETHLEHEM ALARM ADMINISTRATOR, 10 EAST CHURCH ST, BETHLEHEM, PA 18018
CALL CRIME PREVENTION (610-865-7181) WITH QUESTIONS
ST
NOTE: THERE IS A $25.00 PENALTY FOR FAILING TO RENEW THE REGISTRATION AFTER JANUARY 31
OF EACH YEAR
Form EA121212
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Download Form EA121212 "Alarm System Registration & Renewal Form" - City of Bethlehem, Pennsylvania

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