HPD-130 (Rev. 08-16) Pg. 1 of 2
Fee: $25.00
For Administrative Use Only
Receipt #:
Permit #:
Issue Date:
Expiration Date:
Applicant/Business Information
Section 709.02 of the Hilliard City Code requires that individuals and businesses who maintain a security, a fire or
a medical alarm system must apply biennially for a permit. If you or your business maintains an alarm system,
please complete the following application in its entirety. Failure to obtain your permit could result in the issuance
of a citation and fine. If you no longer maintain an alarm system, please complete the Removal Certificate on
page two.
New Permit
Renewal. Current Permit Expires:
Resident/Business Name:
Street Address:
Alarm Information
Classification of Alarm:
Audible Only Fire Only Medical Only Direct Connect to Monitoring Company
If Applicable, Monitoring Company Name:
If Applicable, Monitoring Company Telephone #:
Emergency Contact Information
Please list individuals whom we can contact if your alarm activates. If the alarm is in a residence, please list
contact information for the adult occupant(s) first.
Occupant Name:
Primary Phone #:
Secondary Phone #:
Contact Name:
Primary Phone #:
Secondary Phone #:
Contact Name:
Primary Phone #:
Secondary Phone #:
Residential Alarm Systems
If the alarm is located in a business, skip this section. If the alarm is located in a residence, please read the
following and check the box if the statement is applicable.
I certify that I am at least sixty-five (65) years of age and that the permit being applied for pertains to my
residence, not a business. Due to my age, I claim exemption from the permit fee.
My date of birth is:
I certify that by nature of my occupation pursuant to ORC 149.43(A)(7), the information listed on this document
is exempt from public records requests and should be kept confidential.
My occupation is:
Hilliard Division of Police
5171 Northwest Parkway, Hilliard, OH 43026
Phone: 614.876.2429 Email: hilliardpolice@hilliardohio.gov
HPD-130 (Rev. 08-16) Pg. 2 of 2
Person Completing Form
By signing this application, I hereby apply to the Chief of Police for a security, fire and/or medical alarm permit
and agree to abide by all the rules, regulations and ordinances of the city and applicable state and federal laws
which govern such permit activity.
Printed Name:
Once your application is complete, please do the following:
Enclose the application in an envelope.
Enclose a check or money order made payable to “City of Hilliard” for the $25.00 biennial fee.
However, if the permit applies to a residence where the occupant is at least 65 years or older AND
the senior citizen has marked the appropriate waiver and noted their date of birth, no permit fee is
Mail application and $25.00 fee to: Hilliard Division of Police
License/Permit Bureau
5171 Northwest Parkway
Hilliard, OH 43026
Special Notes
False or incorrect statements made on this application, misconduct on the part of the business, company or
applicant, employee, or failure to conform to the rules, regulations, laws, or ordinances will be considered
cause for denial, revocation of the License/Permit. Direct Connect to E-911 is prohibited.
All fees are NOT refundable.
Section 709.02(a.) Hilliard City Code "Equipment Maintenance and Inspection of Alarm Systems" states (in
part): All equipment used in installations for which a permit is required shall meet the applicable standards
of the Underwriters Laboratory of the United States of America and Canada, Factory Manual, or other
recognized industry standard. Applicants may be required to submit evidence of the reliability of the
equipment installed.
Section 709.08, Hilliard City Code provides that no more than two (2) false alarms per permit year are
allowed. An excessive number of false alarms may make you liable for a fine plus court cost and/or
revocation of your permit. If you exceeded the number of permissible alarms last year, you are cautioned
to take steps to repair any malfunctioning equipment and/or re-educate any persons using the alarm as to
its proper operation.
Per the Ohio Revised Code, information provided on this application may be considered a public record and
may be subject to release through a public records request. The ORC allows certain exemptions of the
public records law based on a person’s occupation.
Questions? Please call Nancy at (614) 334-2338 with any questions concerning your alarm permit.
Certificate Removal
By completing the following section, I hereby certify that I no longer maintain a police/fire alarm system and
request that my alarm permit information be removed from your computer.
Date Removal is Requested:
Address Where Information is to be Removed:
Have You Moved From This Location?
Yes No