Supervised Wireless Security Packaged for Self Installation with available A4Alarm 24 Hour Monitoring

"Affordable Alarms Subscriber Data Form"

24 Hour Nationwide Monitoring Service


 Name * = The Person Entering This Order
Email Address * = YOUR EMAIL ADDRESS, To Send Back a Confirmation TO YOU.

(* Fields marked with an asterisk are required fields)
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"This is a Secure Page when sent to A4Alarms.com"
 

Name *
E-mail Address *
ENTER 8 DIGIT SUBSCRIBER ACCOUNT NUMBER: *
Leave blank if new account.
ALARM COMPANY: *
SPECIAL PROMOTION CODE:
Enter Special Comments or Orders below.
WHY IS FORM BEING SUBMITTED? *
CONTACT PHONE NUMBER (IF WE HAVE QUESTIONS): *
TYPE OF PROTECTED PREMISES *
PREMISES NAME *
ADDRESS LINE #1 *
ADDRESS LINE #2
CITY*_______________________________________________>
STATE*_____________________________________________>
ZIP CODE*_________________________________________>
PREMISES ABORT / CANCEL PASSWORD (12 SPACES MAX.) *
BURGLARY SIGNAL CALL-OUT SEQUENCE *
SPECIAL BURGLARY CALL-OUT REQUEST IF NOT SELECTED ABOVE
1ST CALL PREMISES NUMBER WITH AREA CODE *
ADDITIONAL PREMISES NUMBER WITH AREA CODE
KEYHOLDER #1 NAME & PHONE NUMBER WITH AREA CODE
KEYHOLDER #2 NAME & PHONE NUMBER WITH AREA CODE
KEYHOLDER #3 NAME & PHONE NUMBER WITH AREA CODE
KEYHOLDER #4 NAME & PHONE NUMBER WITH AREA CODE
KEYHOLDER #5 NAME & PHONE NUMBER WITH AREA CODE
KEYHOLDER #6 NAME & PHONE NUMBER WITH AREA CODE

If you know the 7 digit phone numbers for the following
please add or Affordable Alarms will supply them for you.

POLICE DEPT. NAME & NUMBER WITH AREA CODE
FIRE DEPT. NAME & NUMBER WITH AREA CODE
MEDICAL DEPT. NAME & NUMBER WITH AREA CODE

ANY SPECIAL COMMENTS ON THIS ACCOUNT ? - ADDITIONAL INFORMATION ON ZONES, KEYHOLDERS OR ANYTHING ?

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* Fields marked with an asterisk are required fields

PRIVACY STATEMENT: It is the policy and practice of Affordable Alarms (A4Alarms)
to not disclose your private information to anyone without your expressed permission other
than the necessary providers or enablers of the services you have subscribed to.

Affordable Alarms (A4Alarms.com)

24 Hour Nationwide Monitoring Service