LINE #:__________________________________PERMIT #:________________

LOCATION OF DISPATCH CENTER: 46 Lyme Road, Hanover, NH 03755

The following application must be completely filled out before a permit will be issued. All information must be accurate and current. It is the responsibility of the applicant to keep the information up to date and to review the information for accuracy at quarterly intervals. It is also the responsibility of the applicant to test their alarm at least once a year.
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APPLICANTS: (Please fill out)

NAME: _______________________________________TEL #: ______________

ALARM ADDRESS: ___________________________________________________

ALARM FOR: [ ] Business [ ] Residence [ ] Other ________________

ALARM INSTALLED OR MAINTAINED BY:

NAME: _______________________________________TEL #: ________________

ADDRESS: ___________________________________________________________

TYPE OF NOTIFICATION: [ ] Local Alarm [ ] Direct Connection
[ ] Automatic Dialer [ ] Digital Communicator

PROTECTION FOR: [ ] Fire [ ] Burglary [ ] Hold up [ ] Panic
[ ] Medical Emergency [ ] Freeze Up [ ] Chlorine Alarm
[ ] Restore [ ] System Trouble [ ] Other ________________

NAME OF PERSONS TO CONTACT IN THE EVENT OF AN ALARM:

1. Name: __________________________________________________________

Telephone: Day _____________________ Night ____________________

Address: ________________________________________________________

2. Name: __________________________________________________________

Telephone: Day _____________________ Night ____________________

Address: ________________________________________________________

3. Name: __________________________________________________________

Telephone: Day _____________________ Night ____________________

Address: ________________________________________________________

AREA ALARMED: ___________________________________________________

LOCATION OF RESET:_______________________________________________

DIRECTIONS TO PROPERTY: _________________________________________

____________________________________________________________________

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APPLICANT'S SIGNATURE: ___________________________

[OR] AUTHORIZED AGENT: ___________________________

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FEE SCHEDULE:

___ Connection Fee: (one time only) $ 25.00

___ Annual Monitoring Fee: $400.00/yearly

___ Annual Monitoring Fee - Master Fire Box: $300.00/box/yearly

PRO-RATED MONTHLY MONITORING FEE:

False Alarm Charge:

(A) Fire Service Alarm:
After Three False Fire Alarms $100.00 each

(B) Police Service Alarm
After Three False Police Alarms $ 50.00 each

PENALTY CHARGE FOR INACCURATE CALL LIST: $ 10.00

This Appendix was amended 07/10/00