NEWINGTON POLICE DEPARTMENT

71 FOX POINT ROAD

NEWINGTON, NH 03801-2795

FAX: 436-3998

EMERGENCY NOTIFICATION INFORMATION FORM

(Please type or print clearly)

DATE_________________________

NAME OF STORE/BUSINESS____________________________________

ADDRESS____________________________________________________

(Mailing address if different from above)___________________________

CURRENT TELEPHONE NUMBER____________________

NAME, ADDRESS, & TELEPHONE NUMBER OF ALARM MONITORING COMPANY

______________________________________________________________

______________________________________________________________

EMERGENCY NOTIFICATION (Name and Telephone Number)

1.____________________________________________________________

2.____________________________________________________________

3.____________________________________________________________

Name and Address of On-Site Manager or CEO:

_____________________________________________________________

(Office use only) ALARM BOX NUMBER_______________