Alarm Application
* Required fields must be completed

Address and Applicant Information

Type*

Business/Resident Name*
Street Address*
City* State* Zip*

Same as Alarm Address

Mailing Address*
Mailing City * Mailing State* Mailing Zip*

Contact Information

Property Owner * Primary Phone*
Secondary Phone #: Email*
Owner's Address*
City* State* Zip*
Driver's License Number* Driver's License State*

Animals on Premise?* Yes No

Alarm Company Information

Type of System Installed

select

Alarm Monitoring Company* Phone #:*
Alarm Servicing Company Phone #:

Emergency Notification

List two responsible representatives (other than the applicant) who will have keys and respond within 30 minutes to an alarm activation to assist the police in determining the cause of the alarm activation and to secure the premises (if no one within 30 minutes has a key, list someone who could help us get in touch with you).

Alternate Contact Person 1* Primary Phone #* Secondary Phone #
Alternate Contact Person 2 Primary Phone # Secondary Phone #

Agreement

Registration of an alarm system is not intended to, nor will it, create a contract, duty or obligation, either expressed or implied, of response by the City of Des Moines Police Department. Any and all liability and consequential damage resulting from failure to respond to a notification is hereby disclaimed and governmental immunity as provided by law is retained. By registering an alarm system, the alarm user acknowledges that police response may be based on many factors, including but not limited to availability of police units, priority of calls, weather conditions, traffic conditions, emergency conditions, and staffing levels.

Executed this I, by submitting this application accept the conditions and declare under penalty of perjury the foregoing is true and correct.

Please sign your name below, using the mouse or your touch screen enabled device.