POLK COUNTY EMERGENCY SERVICES

Mail to: Polk County Fire Prevention Program

Post Office Box 308

Columbus, NC 28722

FIRE ALARM REGISTRATION APPLICATION

Application Type: (please circle one) Initial Registration Re-Registration

Applicant Name: Telephone # ( )

Last First MI

Applicant Address:

Street Address Apartment or Suite No.

City State Zip code

Business Name: Telephone # ( )

Business Address:

Street Address Apartment or Suite No.

City State Zip code

Building Owner Name (if other than applicant): Telephone # ( )

Owner’s Address

Street Address Apartment or Suite No.

City State Zip Code

Mailing Address

(if different):

Street Address Apartment or Suite No.

City State Zip code

Type of Alarm Site: (please circle one) Residence Business Government Office

Date of Alarm Installation: Number of actuating devices:

Monitoring Company: Telephone # ( ) State licensing#:

Address:

Street Address Apartment or Suite No.

City State Zip code

Please list at least two (2) Emergency Contacts that have agreed to respond and grant access to the alarm site

Name of Contact #1: Local Telephone # ( )

Street Address Apartment or Suite No. City State Zip code

Name of Contact #2: Local Telephone # ( )

Street Address Apartment or Suite No. City State Zip code

x Date:

Signature of Applicant of Authorized Agent

The applicant or Authorized Agent affirms that all the information contained herein is true and correct to the best of his/her knowledge. This application may be denied for false statements and/or non payment of all fees owed to the County of Polk.

NOTE: There is a $5.00 registration fee. Please send check with application.

~Fire Prevention Office Use Only~

Date received: By: Registration #