DEPARTMENT OF PUBLIC SAFETY HELP DESK FORM

2. Name:

   Please provide your name.

3. Business Name:

   Please list the business name.

5. Phone Number:

   Please provide the best number to reach you.

6. Email Address:

   Please provide your business email address.

8. Street Address:

   Please provide the business street address (do not list PO boxes here).

10. Address 2:

    Please provide additional details such as suite, or common-place address (e.g. Park City Center, suite X, etc.).

12. Mailing Address:

    Please provide a mailing address if different from the business physical address.

14. City:

    Please identify your city address.

15. Municipality:

    Please list your municipality (township, borough, etc.).

17. Zip Code:

    Please provide your zip code.

18. Business Type:

    Please list what kind of business you operate (e.g., retail, repair shop, factory, etc.).

20. Hours of Operation

    Please share your typical hours of operation.

22. ALARM INFORMATION
24. Alarm:

    1. Yes
    2. No

    Does your business have an alarm system?

25. Alarm Company:

    Please provide your alarm company name (if applicable).

26. Phone Number:

    Please provide your alarm company phone number (if applicable).

28. Cameras:

    1. Yes
    2. No

    Does your company have recorded surveillance cameras?

29. Camera Locations:

    1. Inside
    2. Outside

    1. Drive Thru
    2. Other (Please describe in comments)

    If "YES", please identify where cameras are located.

31. EMERGENCY CONTACTS
35. Contact 1 Name:
36. Phone Number:
38. Contact 2 Name:
39. Phone Number:
41. Contact 3 Name:
42. Phone Number:
44. Contact 4 Name:
45. Phone Number:
47. Comments:

    Please provide any additional details you consider necessary.

Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

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