Sign-Up For 911 Alarm Monitoring Service.
Please provide the following information, and we will start the process. 911 Alarm will keep confidential all information you supply, except as you authorize us.

Your Name: *REQUIRED 
Your Email Address: *REQUIRED

ABOUT THE LOCATION (the Premises) THE SECURITY SYSTEM IS INSTALLED. 
The Premises Name: (Your Name(s) if your house, otherwise the Business Name)

The Premises Address:
Street Number: Street Name:
City: State: Zip:
The nearest Cross Street:

The Premises area code and telephone #:

The Premises area code and telephone # that the Security System
(RJ31X jack) is/will be connected to. This number may be the same
as the Premises number above:

Type of Premises where the Security System is/will be installed:
What Time Zone is the Premises in:
Select a Password ("all OK" word) to cancel false alarms:


ABOUT YOUR SECURITY SYSTEM.
Is your Security System already installed? 
What is the Brand of your Security System: 
What is the Model of your Security System: 
Is your Security System presently monitored? By which company? 
Is your security system presently functioning properly? 
When was your security system installed? 
In order for your Security System to be reprogrammed, it is necessary
that you have the so-called Installer-Master Programming Code (MPC)
(usually 4 digits) and that your system has not had the "local programming lockout"
feature activated by the installing company. 
Do you have the Master Programming Code (MPC)? 
Who installed your Security System? 
Can you reprogram your Security System to dial our telephone number? 

What transmission format does your Security System transmit? 
(select the first format your system supports)
Can your Security System have a 4 digit or a 3 digit account number?


ABOUT MONITORING.
Upon our receipt of an alarm signal from your security system, dispatchers in our monitoring
station will attempt contact at the telephone numbers provided by you:
   More about monitoring.
> Premises Verify: telephone the alarm location (your home or business)
   to verify that no emergency exists, by asking for and receiving 
   the secret Password you have chosen from anyone who answers. 
   If that person does not tell us the Password, we may elect to 
   telephone one or more Call-List (yourself, neighbors, employees, etc) 
   telephone numbers in an attempt to verify that no emergency exists, 
   then, if necessary,
> Call-List Verify: for burglary alarm signals, telephone, in the order listed, 
   up to three Call-List telephone numbers (excluding pagers), and notify 
   the first adult or Call-List person contacted of the alarm signal received, 
   and ask if they request that police (or other Responders) be notified, 
   then, if necessary,
> Responder Notification: telephone the Responders (police, fire, etc, or others 
   specified by you) and notify them of the alarm signal, and then
> Call-List Notification: if no Call-List person had been contacted, then later 
   telephone the other Call-List telephone numbers, in the order provided, 
   and notify the first person contacted of the alarm signal, or, 
   if no person was contacted, attempt to leave a message.
> This Two-Step Verification and Notification proceedure is designed to reduce false alarms.
   If it is not appropriate for your needs, our monitoring automation system allows
   us to customize our response to fit your varied needs. Let us know if your needs
   are different. All services are provided pursuant to the 911 Alarm Monitoring
   Service Agreement which more fully describes the manner and timing of any
   Verification or Notification calls we may make.

Alarm Signals to be monitored for:
The Security System's Zones are for these specific Alarm Conditions 
(Burglary, Fire, Robbery (silent alarm), Emergency-Call (audible "panic" alarm)
in these Areas (Specify Area: front door, hallway, left side windows, etc):
Zone 1:  Area:
Zone 2:  Area:
Zone 3:  Area:
Zone 4:  Area:
Zone 5:  Area:
Zone 6:  Area:
Zone 7:  Area:
Zone 8:  Area:
Zone 9:  Area:
Zone 10: Area:
Zone 11: Area:
Zone 12: Area:
Zone 13: Area:
Zone 14: Area:
Zone 15: Area:
Zone 16: Area:


More than 16 alarm zones?


The Security System's Keypad has manually-activated buttons 
to transmit Alarm Signals for these conditions:
Button A: 
Button B: 
Button C: 

WHO SHALL WE NOTIFY?
Premises (to verify the alarm condition):
Premises area code and telephone #:

Police Department (for Burglary, Robbery and Emergency-Call Alarm Signals):
Police Dept Name:
Police Dept area code and telephone # (not "911"):
 
Fire Department (for Fire Alarm Signals):
Fire Dept Name:
Fire Dept area code and telephone # (not "911"):
 
Call-List names, USA area code and telephone #'s
(list in the order to be called, include yourself if appropriate.
Do not list numbers that have anonymous-call rejection service:
1. Name:  Area code & telephone #:
2. Name:  Area code & telephone #:
3. Name:  Area code & telephone #:

ABOUT YOU.
Your Name: (please enter it again)

Your Email Address: (please enter it again)

Your Business Name (if applicable):

Your Billing Address: Street Number & Name or P.O.Box:

Your Billing Address: City / State / Zip:

Your area code and telephone # day:

Your area code and telephone # evening:

Your fax telephone #:

How did you learn about 911 Alarm:

If your system is presently monitored, how much do you pay?

How Do You Like the 911 Alarm site?



PAYMENT. 
The charge for 911 Alarm Monitoring Service for 12 months is 
$11.99 per month (payable annually in advance $143.88), plus a one-time 
$25.00 processing/setup charge, for a total of $168.88. The renewal rate is $143.88 annually.
How will you be paying?


If you are paying by credit card, after completing this form,
click below to SEND this form to us. This is the fastest method, 
and is used by most of our subscribers.

If you prefer, after completing this form and printing a copy on your printer,
(ii) delete your credit card number then click below to SEND this form to us,
(iii) then mail the printed copy to us at
911 Alarm, 2801 San Pablo Avenue, Berkeley CA 94702-2238, or, 
if you prefer, fax it to us at 510-548-8500.

If you are paying by check, after completing this form,
(i) print a copy on your printer,
(ii) then click below to SEND this form to us,
(iii) then mail the copy together with your check for $168.88 to us at
911 Alarm, 2801 San Pablo Avenue, Berkeley CA 94702-2238.

Credit Card authorization.

Name on card:
Account #:  Expiration Date:


Do you have any other questions or comments?

When done, press
Our staff will promptly prepare and mail a monitoring service agreement to you for your review and approval. Thank you for choosing 911 Alarm. If you have any questions, call us at 510-444-8888 x2.

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All services are provided pursuant to the terms and conditions of the 911 Alarm Monitoring Service Agreement.
© 911 Inc 1995-2007.     911 Alarm ® is a registered trademark.     Updated 10-22-2007.