Form Center

2. 
3. Department of Public Safety – Police Division
5. This permit is authorization for an alarm system for the identified location only. Additional sites require additional permits. This permit is not intended to certify operability or effectiveness of the alarm equipment system or any portion thereof. The issuing agency reserves the right to revoke this permit for violations of any state law or ordinance relating to the operation of the alarm system.
7. First Name (Business Resident)*
8. Last Name*
10. Address*
12. City*
13. State*
14. Zip Code*
15. Phone Number*
17. First Name (Billing Information)*
18. Last Name*
20. Address*
22. City*
23. State*
24. Zip Code*
25. Phone Number*
29. BUSINESS HOURS:
31. Mon*
    Mon Start Time

    —

    Mon End Time
32. Tue*
    Tue Start Time

    —

    Tue End Time
33. Wed*
    Wed Start Time

    —

    Wed End Time
34. Thur*
    Thur Start Time

    —

    Thur End Time
36. Fri*
    Fri Start Time

    —

    Fri End Time
37. Sat*
    Sat Start Time

    —

    Sat End Time
38. Sun*
    Sun Start Time

    —

    Sun End Time
42. EMERGENCY CONTACTS: (Three are required. List in preferred calling order.)
44. First Name*
45. Last Name*
47. Address*
49. City*
50. State*
51. Zip Code*
52. Phone Number*
54. First Name*
55. Last Name*
57. Address*
59. City*
60. State*
61. Zip Code*
62. Phone Number*
64. First Name*
65. Last Name*
67. Address*
69. City*
70. State*
71. Zip Code*
72. Phone Number*
76. GENERAL INFORMATION:
78. Business Type*
    -- Select One --Bank or Credit UnionSingle ResidenceMultiple DwellingOther
79. Exit Doors?*

    1. North
    2. South
    3. East
    4. West
    5. NE
    6. NW
    7. SE
    8. SW
81. Any Weapons on Premises?*

    1. Yes
    2. No
82. If "Yes," Select Weapons Type

    1. Rifle
    2. Shotgun
    3. Handgun
    4. Other
83. Where are the Weapons Kept?
87. ALARM INFORMATION
89. Date Alarm Installed*
    Date Alarm Installed
90. Alarm Type*

    1. On-Premise Audible?
    2. Monitored by Alarm Company?
92. Alarm Company Name*
93. Phone Number*
95. Address*
97. City*
98. State*
99. Zip Code*
101. Electronic Signature Agreement

     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.
103. Electronic Signature
Leave This Blank:


104. 1. Receive an email copy of this form.
105. Email address

     This field is not part of the form submission.

106. Submit

* indicates a required field