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2. Applicant's Name as Registered with Alarm Company
4. Applicant's Address
6. Applicant's Phone
7. Applicant's Cellular Phone
9. Name of Alarm Company
11. Alarm Company Address
13. Alarm Company Phone
14. Date Alarm Installed
    Date Alarm Installed
16. Fees

    1. Initial Registration - $25
    2. Renewal - $5

    Make checks payable to the Township of Bloomfield.
    
    Permit period: January 1 thru December 31
    
    There will be no prorating should you decide to disconnect during the year, at your request, or that of the municipality.
18. Emergency Keyholder Contact List (must list three)
20. Name*
21. Address*
22. Phone*
24. Name*
25. Address*
26. Phone*
28. Name*
29. Address*
30. Phone*
32. Name
33. Address
34. Phone
36. Indemnification: By installing an alarm system and registering same with the Township, each alarm user agrees to indemnify and hold harmless the Township, its agents, servants and employees from and against all claims, suits, damages, costs, losses and expenses, and to release the Township, its agents, servants and employees from any and all liability or damages in any way resulting from or arising out of or connected with the installation, operation, or maintenance of the alarm system or any act or omission connected therewith.
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37. Print Only

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