VILLAGE OF SOUTH HOLLAND

VILLAGE OF SOUTH HOLLAND RESIDENTIAL ALARM PERMIT RENEWAL
Permit Number*
Check box if no changes to key holders

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Type of Alarm

FireBurglarMedical
First Name
Last Name
Address Where Alarm is Installed
City, State, Zip Code
Home Phone
Cell Phone
Email Address
Additional Key Holder - #1 Last Name
First Name
Home/Work Phone
Cell Phone
Additional Key Holder - #2 Last Name
First Name
Home/Work Phone
Cell Phone
Additional Key Holder - #3 Last Name
First Name
Home/Work Phone
Cell Phone
Alarm Company
Address
City, State, Zip Code
Phone Number
Signature of Permit Holder
Date
Residential Alarm Permit Registration Fee is $25.00. Please make checks payable to the Village of South Holland. Payment must be returned with this form to the Police Department - 16220 Wausau Avenue, South Holland, IL 60473. Phone inquiries, call (708) 331-3131.
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VILLAGE OF SOUTH HOLLAND RESIDENTIAL ALARM PERMIT RENEWAL