Village of Inverness
1400 Baldwin Road, Inverness, Illinois 60067
(847) 358-7740 - Fax (847) 358-8774
PERMIT APPLICATION FOR ALARM SYSTEM
(Permits are not transferable)
Resident’s Name
Street Address
Telephone Cell Phone #1 Cell Phone #2
Please select a 4 Digit PIN for Phone Verification: __________ __________ __________ __________
Name of Alarm Company Alarm Company Phone Number
The undersigned agree to provide Inverness Police Department and the applicable fire district personnel with access to the premises at
all times for the purpose of investigating emergency calls and to provide the following information for that purpose:
1. Key Holder Name: _____________________________________________________________________________________
_____________________________________________________________________________________
Telephone Cell Phone
2. Key Holder Name: _____________________________________________________________________________________
_____________________________________________________________________________________
Telephone Cell Phone
3. Key Holder Name: _____________________________________________________________________________________
_____________________________________________________________________________________
Telephone Cell Phone
The undersigned understands that the Village of Inverness and its respective officers, employees, and agents shall not be liable for and
are hereby released from liability for any failure of service or damages, including but not limited to damages resulting from breaking in
to gain entrance, that might result from and/or may arise in any way as a result of the installation or operation of any alarm system,
alarm connection and/or alarm service. The undersigned further agrees to indemnify the Village of Inverness and their respective
officers, employees and agents for all claims, demands, judgments, liability costs and expenses that might result from and/or may arise
in any way as a result of any alarm systems, the alarm connection and/or alarm service.
Signature Date
Received by Village Date
Updated: ________________ Updated: ________________ Updated: _______________ Updated: _______________
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signature
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