The Rutherford Police Department |
Alarm Registration |
| Name of Applicant: | _____________________________________________________ |
| Address: | _____________________________________________________ |
| Telephone Number: | _____________________________________________________ |
| Name of Alarm Company: | _____________________________________________________ |
| Address: | _____________________________________________________ |
| Telephone Number: | _____________________________________________________ |
| Type of Alarm (circle all that apply) |
| Burglar Fire Holdup Medical Panic |
| Central Station Connection? Yes/No |
| Direct Connection to the Rutherford Police Department? Yes/No |
| Recorded Message to the Rutherford Police Department? (dial alarm) Yes/No |
| Outside Audible? Yes/No |
**On page two of this form, please list the names and addresses of three emergency contacts.**
| ______________________________ |
| Signature/Date |
| Return To: The Rutherford Police Department, Record Bureau, 184 Park Avenue, Rutherford, New Jersey, 07070 |