VILLAGE OF POWELL

APPLICATION NUMBER:

APPLICATION WILL EXPIRE ON

APPLICATION FOR ALARM USER LICENSE

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ORDINANCE 92-18

1 .

NAME OF APPLICANT(S)

-

ADDRESS

PHONE NUMBER

2.

PROPERTY TO BE SERVED:

LOCATION or PROPERTY

LAND OWNER(S)

PHONE NUMBER

3.

EMERGENCY CONTACT PERSON(S).'

NAME

ADDRESS

PHONE NUMBER

4.

ALARM MONITORING COMPANY:

NAME

I

ADDRESS

PHONE NUMBER

CONTACT PERSON

ACCOUNT NUMBER

i

. TYPE OF ALARM

S.

ATTACH FEE FOR APPLICATION ($25.00)

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

THE UNDERSIGNED ACKNOWLEDGES THE RECEIPT OF ORDINANCE 92-18 AND
UNDERSTANDS SAID ORDINANCE.

1,

APPLICANT'S SIGNATURE (S)

DATE

APPLICATION ACCEPTED BY:

I

DIRECTOR OF PUBLIC SAFETY

DATE

I

...

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