Contact CSC – Residential 1Contact Information2Signal Verification3Emergency Call List * Denotes Required FieldPlease check one* Existing New Account Customer's Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* Is this an apartment or condominium or other multi-family complex?* Yes No If yes, what floor do you live on? OptionalResponding Agencies:Police Dept. (Name) Police Dept. (Name)Police Phone (Not 911) Police Phone (Not 911)Permit Number Permit NumberFire Dept. (Name) Fire Dept. (Name)Fire Phone (Not 911) Fire Phone (Not 911)Permit Number Permit NumberEMT (Name) EMT (Name)EMT Phone (Not 911) EMT Phone (Not 911)Permit Number Permit NumberSecurity Guard Security GuardSecurity Guard Phone Security Guard Phone Fire, Medical, Hold-up and Panic Alarms will be dispatched upon receipt of the signal in the Monitoring Station. Burglary Alarms will be handled as you designate below.Please select ONE of the following procedure options that you would like CSC to follow in case we receive a Burglary Alarm signal.* Single-call VerificationCSC will call the primary contact listed before dispatching the authorities. Two-call VerificationCSC will call the first emergency contact listed. If there is no response, CSC will attempt to call the second contact provided before dispatching the authorities. Please initial if you DO NOT want to be contacted for: low battery or failure to communicate between the hours of 10:00 p.m. and 7:00 a.m. Otherwise, we will contact you after 7:00 a.m.Initial here: Important: If you accidentally set off your alarm, please call CSC right away at (317) 543-1300. For your safety, you must provide your chosen password to CSC when an alarm is reported; failure to give your (correct) password may result in authority response. CSC is not responsible for fines from your local authorities due to a false alarm. We urge you to test your system frequently. If you are having any issues, please contact our Service Department at (317) 543-1300. First Contact Name* Primary Phone*Secondary PhonePassword* Authorized to make changes* Yes No Second Contact Name* Primary Phone*Secondary PhonePassword* Authorized to make changes* Yes No Third Contact Name* Primary Phone*Secondary PhonePassword* Authorized to make changes* Yes No Fourth Contact Name Primary PhoneSecondary PhonePassword Authorized to make changes Yes No Fifth Contact Name Primary PhoneSecondary PhonePassword Authorized to make changes Yes No I understand that it is my responsibility to contact the local police authority to apply for and obtain any alarm license and/or alarm permit as required. SignaturePrinted Name* Password* Please provide your chosen password in the designated space so we may properly identify you as an authorized user on this account.Date Signed* MM slash DD slash YYYY By signing this document, I affirm that all of the information provided is accurate and up-to-date.