Vermont State Police



|Vermont State Police |[pic] |Phone: 802-241-5397 |

|45 State Drive | |State Police Use Only: |

|Waterbury, VT 05671-1300 | |Alarm # |

|ALARM REGISTRATION |

|Mail this form along with a check in the amount of $50.00 to: |

|Vermont State Police |

|ATTN: Alarm Coordinator |

|45 State Drive |

|Waterbury, VT 05671-1300 |

|Please make checks payable to The Department of Public Safety. There is a $20.00 fee for any returned checks. |

|PROPERTY OWNER |

|Name - First |Middle |Last |Date of Birth (mm/dd/yyyy) |

|      |      |      |      |

|Driver’s License Number |State |

|      |      |

|ALARMED PROPERTY INFORMATION |

|If this is a business, please list the name of the business: |

|Premise Phone # |911 Property Number and Street Address |Town, Zip Code |

|Previous Property Owner(s) Name(s):       |

|If owner’s primary residence is not the alarmed residence, please complete the following: |

|Legal Address |Mailing Address (if different from legal) |

|      |      |

|Owner Contact Numbers |Home |(     )      -      |Work |(     )      -      Ext.       |

| |Cell |(     )      -      |Email |      |

|Alarm Code/Word (to be given to the State Police for verification purposes only. This Alarm Code/Word doesn’t need to be the pin # to your alarm system |

|this can be a series of numbers or words to be given to the State Police in the event of an alarm activation):       |

|ALARM MONITORING COMPANY |24 Hour Dispatch Center |

| | (     )      -      |

|ALARM INSTALLATION/SERVICE COMPANY TELEPHONE NUMBER |

|      | (     )      -      |

|ACKNOWLEDGEMENT |

|I acknowledge that the Vermont State Police bear no responsibility for the performance of the alarm equipment. Furthermore, I have read the State Police |

|policy and understand that State Police response will be determined based on past performance and history of my alarm system and the circumstances at the |

|time of the alarm activation. |

|I acknowledge that after the 1st false alarm (within a calendar year), there will be a fee assessed for future false alarms and payment must be received |

|within 30 days of the invoice date to avoid being placed in non-response mode. I also acknowledge that after three (3) false alarms (per calendar year), my|

|alarm will be placed in non-response mode. At that time, should I wish to have the State Police begin responding again, I must comply with the |

|reinstatement policy and procedures. I understand that my alarm will remain in non-response mode until compliance with the reinstatement policy and |

|procedures are met. |

|I acknowledge that it is my responsibility to keep all key holder information current with my alarm company and/or monitoring company. I have advised all |

|key holders associated with my account that it’s their responsibility to respond with the State Police for an interior inspection, but sometimes the key |

|holder may be the only resource for responding. Should there be any indication that a crime has occurred or is occurring the responder will contact 911 |

|immediately. |

|I acknowledge that it’s my responsibility that the Vermont State Police has current and correct contact information on file for me or my business. |

|I understand that it’s my responsibility to provide clear and accurate directions to my home or business to the Vermont State Police. |

|Date |Signature of Property Owner |

| | |

|      | |

DPS AF#2 (2019)

|DIRECTIONS TO THE PROPERTY (FROM MAJOR ROADWAY) |

| |

|      |

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