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EMERGENCY PREPAREDNESS INFORMATION

This form is intended to collect vital information required to assist Police, Fire, and Ambulance personnel when responding to your home or business in the event of an emergency. Please take the time to complete the entire form before you submit it. When you have finished filling out the form click the submit button located at the bottom of the form. Your emergency responders appreciate your cooperation in performing this invaluable service.

PLEASE REMEMBER TO ANSWER ALL QUESTIONS

TYPE OF LOCATION: 
BUSINESS / RESIDENCE NAME: 
Street Address: 
Telephone #:  Fax #: 

PROPERTY OWNERS NAME: 
Mailing Address: 
Telephone #:  Fax #: 

Emergency Contact Person(s): Who will respond with a key in the event of an emergency? It is highly recommended using someone that can respond within 15 minutes.
Name:  Telephone #: 
Name:  Telephone #: 
Name:  Telephone #: 

Provide your contractors name and telephone number that performs these services:
Alarm Co:  Telephone #: 
Electrician:  Telephone #: 
Elevator Serv. Co:  Telephone #: 
Fire/Sprinkler Co:  Telephone #: 
Fuel Oil Co:  Telephone #: 
Furnace/Boiler Ser. Co:  Telephone #: 
Generator Serv. Co:  Telephone #: 
Guard Serv. Co:  Telephone #: 
Propane Del. Co:  Telephone #: 

BUSINESS RESIDENCE LOCATION INFORMATION:
How long has your business/residence been at its present location? 
My Business / Residence is on the   – Side of the Street.
Approx.   Feet   of (Cross Street) 
Other descriptive features about your home/business that would help responders locate it in an emergency:
Nearest fire hydrant location:   Feet   of the premise.

Please check all that apply for the above property:



Do you have firearms or reloading supplies on the premise? 
If YES please list all in COMMENTS box below.

If applicable - Driveway Gate Code (For Emergency Responders Only) 
Do you have a KNOX Box at your location? 
If YES where is it located? 
If NO information about Knox Boxes and other Knox Rapid Entry System products can be found at  www.knoxbox.com.

Are there any occupant(s) with Special Needs that reside or frequent your home or business? 
Please check all that apply:
 

Does an occupant require a wheelchair or walker for mobility? 

Does an occupant require oxygen or special life support equipment while at home? 

If required to evacuate during an emergency, will the occupant with special needs require any special equipment, medications, medical personnel or transportation? 
If YES please explain the needs and special instructions: 

COMMENTS:


  Please make sure that you have filled out the above form correctly before submitting it.