Department of Police Services Three Main Street

· Alarm Owner’s Name________________________________________________________________

· Type of Alarm: Residential ( ) Single Home ( ) Apartment ( ) Mobile Home ( ) Condo ( ) Other ____________________

Business ( ) Single Building ( ) Complex ( ) Plaza

· If Commercial what type of Business is conducted _________________________________________

· Mailing Address _______________________ ______________________________________________

· Billing Address ________________________ ______________________________________________

· Telephone ___________________________ ______Emergency Phone _________________________

Alarm User Information (if alarm user is different than alarm owner)

· Name or Business Name ______________________________________________________________

· Mailing Address ____________________________________________________________________

· Billing Address _____________________________________________________________________

· Telephone ___________________________ Emergency Phone _______________________________

Please list (3) Keyholders that may be reached in an emergency and are within (20) twenty minute response time and have permission to the alarm site and can deactivate system if necessary.

· Name _______________________________________Telephone _____________________________

· Address ___________________________________________________________________________

· Name ______________________________________ Telephone _____________________________

· Address ___________________________________________________________________________

· Name ______________________________________ Telephone _____________________________

· Address ___________________________________________________________________________

Alarm System Location Information

· Street Address Location ______________________________________________________________

· Alarm Company: Name, Address & Telephone ____________________________________________

__________________________________________________________________________________

· Please advise any special concerns for alarm site: (i.e.) animals, hazardous materials, weapons, etc.

_______________________________________________________________________________________

· Alarm Installer: Name, Address & Telephone _____________________________________________

· Date of installation ________________________________

· Monitoring Company if Different from Installer: ___________________________________________

· System Type: ( ) Burglary ( ) Panic Alarm ( ) Fire ( ) Hold Up ( ) Intrusion

· Are above checked system types audible or silent? <Circle One> Yes No

· If an exterior audible device is used in the system, is the system automatically restricted to a maximum of twenty (20) minutes? <Circle One> Yes No

Unless required by law, an audible exterior alarm must automatically be

restricted to a maximum of ten (10) minutes.

That a set of written operating instructions for the Alarm System, including written guidelines on how to avoid False Alarms have been left with the applicant by the Alarm Installation Company; and that the Alarm Installation Company has trained the applicant in proper use of the Alarm System, including instructions on how to avoid False Alarms.

That the Alarm Site is properly marked with the street name and street number at the roadside entrance and on the building itself. Markings will be a minimum of three (3) inch lettering in contrasting color to the background and clearly visible from the roadway. That law enforcement or fire department response may be influenced by factors including, but not limited to the availability of units, priority of calls, weather conditions, traffic conditions, emergency conditions, staffing levels, etc.

That access to the Alarm Site shall be free and clear of debris, snow, water, locked gates or fences, etc. allowing safe access to and within the site to include animals on property to be secured. Any false statement of a material fact made by an applicant for the purpose of obtaining an Alarm Registration shall be sufficient cause for refusal to issue a registration.

An Alarm Registration cannot be transferred to another Person or Alarm Site. An Alarm User shall inform the Alarm Administrator of any change that alters any of the information listed on the Alarm Registration application within five (5) business days of such change. All fines and fees owed by an applicant must be paid before an Alarm Registration may be issued or renewed.

Pursuant to the provisions of the Town of Newtown Alarm Ordinance on file with the Town Clerk of Newtown and in consideration for the permission to use an alarm system as defined therein, the undersigned alarm user, as defined therein, acknowledges full familiarity with said ordinance and certifies the user's authorization to register the above identified alarm device. The undersigned further accepts full responsibility for said device as the alarm user within the terms of said ordinance and agrees to fulfill all the requirements stated therein. It is the responsibility of the alarm owner to contact Newtown Department of Police Services if there is a change of address.

Registration Fee: $25.00 Please remit payment when returning completed form.

x _____________________________ ______________________

Alarm Owner Signature Date

Authorization of Administrator

Proper Registration of Alarm Number __________________ is hereby acknowledged.

x _____________________________ ________________________

Administrator Date