WINDSOR POLICE

WINDSOR POLICE DEPARTMENT
29 UNION STREET WINDSOR, VERMONT 05089 PHONE: (802) 674-9042, FAX (802) 674-5189
WILLIAM P. SAMPSON CHIEF OF POLICE
BURGLAR ALARM PERMIT
INCOMPLETE FORMS WILL BE RETURNED WRITE "N/A" WHEN NOT APPLICABLE
BUSINESS PERMIT RESIDENTIAL PERMIT
OWNER TENANT
FULL NAME OF PERSON RESPONSIBLE FOR PERMIT
BUSINESS NAME:
IF PERMIT is FOR A BUSINESS BUSINESS NAME
PHONE:
ADDRESS OF ALARMED PREMISES
BUILDING #
APT/SUITE
SUBDIVISION
CITY
STATE
ZIP
DRIVER'S LICENSE NUMBER
STATE
E MAIL ADDRESS
example@example.com
SECONDARY E MAIL ADDRESS
example@example.com
TELEPHONE NUMBERS: HOME: BILLING ADDRESS WOULD LIKE TO RECEIVE MY INVOICE STATEMENTS AT THIS ADDRESS: ADDRESS:PHONE: , IF DIFFERENT FROM ABOVE
MOBILE:
CITY
STATE
ZIP
DRIVER'S LICENSE NUMBER
STATE
EMERGENCY CONTACTS: (LIST PERSONS WITH KEYS WHO CAN RESPOND TO THE ALARM WITHIN 15 MINUTES)
NAME
NAME
NIGHT
PHONE:
NIGHT
ALARM co. NAME
STATE LICENSE #
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
MONITORING co. NAME
STATE LICENSE #
PHONE:
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Ihereby agree to comply with all of the requirements of the West Windsor Burglar Alarm Ordinance. I understand that I am responsible for all fines for excessive false alarms and alarm response will be discontinued for non-payment and/or excessive false alarms.
SIGNATURE

Clear
DATE

MonthDayYear
Date
Upon completion. please deliver or mail to: Windsor Police Department, 29 Union Street, Windsor, VT 05089
FOR WINDSOR POLICE USE ONLY
RECEIPT DATE:
Should be Empty: