Alarm System Registration Application

 

MEDINA POLICE DEPARTMENT
501 Evergreen Point Road
Medina, Washington  98039
Phone:  425.233.6420  Fax:  425.637.3989
www.medina-wa.gov

 

If you have questions, or need assistance completing this form, please contact Linda Crum at 425-233-6422.

* Date of Application:
ex: 12/27/1987
I.  SUBSCRIBER INFORMATION

* OWNER'S NAME(S):
* ADDRESS (include street, city, state and zip):
* MAILING ADDRESS (If different from home address):
* HOME PHONE:
ex: (612) 555-1234
CELL PHONE:
BUSINESS PHONE:
EMAIL ADDRESS:
II.  ALARM COMPANY INFORMATION

* TYPE OF ALARM::
MONITORED
NON-MONITORED (Self-Installed)
ALARM COMPANY:
PHONE:
ex: (612) 555-1234
REPRESENTATIVE NAME (If Known):
III.  EMERGENCY NOTIFICATION

LIST TWO RESPONSIBLE REPRESENTATIVES (OTHER THAN THE SUBSCRIBER) WHO WILL RESPOND WITHIN 15 MINUTES TO AN ALARM ACTIVATION TO ASSIST THE POLICE IN DETERMINING THE CAUSE OF THE ALARM ACTIVATION AND TO SECURE THE PREMISES. MAKE SURE YOUR CONTACT INFORMATION IS CURRENT WITH YOUR ALARM COMPANY AND MEDINA POLICE DEPARTMENT.

* 1. NAME:
* DAY TELEPHONE:
ex: (612) 555-1234
* NIGHT TELEPHONE:
ex: (612) 555-1234
2. NAME:
DAY TELEPHONE:
ex: (612) 555-1234
NIGHT TELEPHONE:
ex: (612) 555-1234
IV.  SECURITY GATES

DO YOU HAVE A SECURITY GATE BLOCKING VEHICULAR ACCESS?:
YES
NO
NAME OF SECURITY GATE COMPANY:
PHONE:
ex: (612) 555-1234
IF KNOX-BOX, DOES IT HAVE A SUBMASTER LOCK FOR BOTH FIRE AND POLICE EMERGENCY ACCESS?:
YES
NO
HAS YOUR GATE BEEN TESTED BY FIRE AND POLICE FOR PROPER ACCESS?:
YES
NO
IN CASE OF POWER FAILURE, WHAT TYPE OF EMERGENCY BACKUP?:
BATTERY
MANUAL (LATCH KEY)
SECURITY GATE MAINTENANCE:
PHONE:
ex: (612) 555-1234

Registration of an alarm system does not create a contract, duty or obligation either expressed or implied for police to respond. Any and all liability and consequential damage resulting from the failure to respond to a notification is hereby disclaimed and governmental immunity as provided by law is retained. By registering an alarm system, the user acknowledges that police response may be based on factors such as availability, priority of calls,weather conditions, traffic conditions, emergency situations and staffing levels.


* - denotes required field