Hanover County Security Alarm Permit Application
Protected Premise Information:
Name of the Business or Protected Premise:__________________________________________________
Street Address:_________________________________________________________________________
Mailing Address:______________________City:__________________________State____ Zip________
Telephone #_____________________ Fax # ______________________Email_______________________
Days and Hours Business Operated ____________________________________________________
Owner and/Operator of the Security System:
Owner/Tenant Name: ________________________________________ Telephone # _________________
Address: ______________________________________________________________________________
Federal Tax ID #: _______________________________________________________________________
Person Applying for the Permit:
Name: ___________________________________________ Title: ________________________________
Relationship or official position in business___________________________________________________
Address: ______________________________City: ________________________ State ____ Zip _______
Telephone # ________________________________ Fax # ______________________________________
Applicant’s Signature: _______________________________________ Date: _______________________
Security Alarm System Information:
Type of System: __________________________________________ Installation Date: _______________
Manufacturer: _______________________________________ Installed By: ________________________
Audible _________ Silent __________ Motion _____________ Other _____________________________
Is the Alarm System Monitored by an Alarm Company: _________ or Direct Dial: ___________________
Alarm Monitoring Company Information:
Name of Company: _________________________________________ Telephone # __________________
Address: _____________________________ City: _______________________ State _____ Zip ________
Key Holder Contact Information:
Name: _____________________________________________ Home Telephone # ___________________
Pager #: _________________________________ Mobile # _____________________________________
Name: _____________________________________________ Home Telephone # ___________________
Pager #: _________________________________ Mobile # _____________________________________
Name: _____________________________________________ Home Telephone # ___________________
Pager #: _________________________________ Mobile # _____________________________________
Hanover County Use Only:
Date Received: ___________________ Approved By: ___________________ Permit # _______________
Date Approved:___________________
Comments: ____________________________________________________________________________
GPIN(S)_______________________________________________________________________________
Signature: ______________________________________________ Date: __________________________
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