PEORIA POLICE DEPARTMENT 
ALARM REGISTRATION APPLICATION 
(Please PRINT Clearly) 


NAME: 	  					DATE: 	
(HOME OCCUPANT/BUSINESS/SCHOOL NAME)

PREMISE ADDRESS:	 
(CITY, STATE  ZIP CODE)

MAILING ADDRESS: 	
(IF DIFFERENT FROM STREET ADDRESS)	             (CITY, STATE  ZIP CODE)

PRIMARY RESPONDER’S NAME: 	

 
PRIMARY RESPONDER’S EMAIL ADDRESS: 	

HOME:   ( )	 WORK: ( )	  CELL: ( )	


ALTERNATE RESPONDING PERSON (NAME)	

HOME:   ( )	 WORK: ( )	  CELL: ( )	

ALARM COMPANY: 	
TELEPHONE NUMBER:  	 ( ) 		 EMAIL: 	
ALARM COMPANY ADDRESS: 	
(CITY, STATE  ZIP CODE

MONITORING ALARM COMPANY: 	
TELEPHONE NUMBER:  	 ( ) 		

*PLEASE ENCLOSE A CHECK OR MONEY ORDER OF $10*
PAYABLE TO THE CITY OF PEORIA 
FOR ANNUAL ALARM SUBSCRIBER PERMIT (CITY OF PEORIA CITY CODE SECTION 2-220)

MAIL THE COMPLETED FORM AND ANY APPLICABLE FEES TO:
PEORIA POLICE DEPARTMENT 
ATTENTION: ALARM COORDINATOR 
8351 WEST CINNABAR AVE. 
PEORIA, ARIZONA 85345 


CONTACT INFORMATION:
PH: (623) 773-7017 FAX: (623) 825-6514 
ALARMS@PEORIAAZ.GOV