Form Center

2. Alarm Type

   1. Burglar
   2. Fire
   3. Hold Up
4. Property Owner Name
5. Occupancy Name
   (If a business)
7. Property Owner Address
8. Occupancy Address
   (If a business)
10. Property Owner Phone
11. Occupancy Phone
13. If a business, what are the normal hours of operation?
15. Are there Firearms on premises?

    1. Yes
    2. No
16. List Types
18. Is there a safe on premises?

    1. Yes
    2. No
19. Location
21. Number of dog(s) on premises
22. Name of Dogs
26. In Case of Emergency - Contact Information
    Please list in order to call
28. Contact 1 Name
29. Phone Number
31. Address
33. Contact 2 Name
34. Phone Number
36. Address
38. Contact 3 Name
39. Phone Number
41. Address
45. If Alarm is Activated - Contact Information
    Fill in only if different than above contacts
47. Contact 1 Name
48. Phone Number
50. Address
52. Contact 2 Name
53. Phone Number
55. Address
57. NOTICE
    Riverside Police Department will make every reasonable attempt to notify the above of an alarm activation, however, the Village is not required to notify anyone and failure to do so does not provide the alarm user any recourse. Further, the owner/occupant is responsible to maintain the accuracy of this information at all times. Complete form in its entirety. IF you have a security system, attach the annual $60.00 fee (pay: VILLAGE OF RIVERSIDE)
59. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
61. Electronic Signature
63. Date/Time
    Date/Time

    Date/Time
Leave This Blank:


64. Print Only

* indicates a required field