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Business Emergency Contact Form

2. 

4. Business Information

6. Name of Business*

7. Business Telephone #*

9. Business Address*

11. City

12. State

13. Zip

15. Owner's Name*

16. Owner Contact Telephone #*

18. Owner's Address (include City, State, ZIP Code)*

22. What are your normal operating hours?*

24. What are your cleaning crew hours?*

26. Does your business have a safe?*

    1. Yes
    2. No
28. Does your business have an alarm system?*

    1. Yes
    2. No

30. Is it an audible alarm?*

    1. Yes
    2. No

32. What type of alarm do you have? (Check all that apply.)*

    1. Burglary
    2. Panic
    3. Smoke
    4. Fire

34. What is the alarm company's name?*

35. Alarm Company Telephone #*

37. Does your business have video surveillance?*

    1. Yes
    2. No

39. Interior Cameras*

    Please provide a count of how many cameras are INSIDE the premises and their direction(s).

41. Exterior Cameras*

    Please provide a count of how many cameras are on the EXTERIOR of the premises and their direction(s).

45. Please provide a list of contact telephone numbers for contact person(s) in the event of an alarm. List them in the order that you would like them contacted. For reach person, list Name/Address/Home Telephone #/Cell #/Date of Birth

47. Contact 1 - First Name*

48. Last Name*

50. Address*

52. Home Telephone #*

53. Cell Phone #*

54. DOB*

56. Contact 2 - First Name

57. Last Name

59. Address

61. Home Telephone #

62. Cell Phone #

63. DOB

65. Contact 3 - First Name

66. Last Name

68. Home Telephone #

69. Cell Phone #

70. DOB

74. Owner/Manager Name*

75. Date*
    Date

77. IMPORTANT
    All information provided and statements made by me are complete, correct, and true to the best of my knowledge. (If submitting this form electronically, I understand that typing my name in the signature box replaces a hand written signature.)

    All information provided and statements made by me are complete, correct, and true to the best of my knowledge. (If submitting this form electronically, I understand that typing my name in the signature box replaces a hand written signature.)

79. The information contained on this form will not be made public. It will remain on file at the Mount Pleasant Police Department.

Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field