Submitting this form allows local police to contact you, in the event of an incident (break-in, fire, unlocked door, etc.) at your business. Information will be used only in the event of an emergency. If you have any questions, please contact the Police Department at 620-378-4152.

Business Information

Business Name*

Business Address*

City*

State*

Zip*

Business Phone*

Business Fax

Emergency Contact Information

First Emergency Contact

Name*

Address*

City*

State*

Zip*

Phone*

Alternate Phone*

Key Holder?*

Yes

No

Second Emergency Contact

Name*

Address*

City*

State*

Zip*

Phone*

Alternate Phone*

Key Holder?*

Yes

No

Third Emergency Contact

Name*

Address*

City*

State*

Zip*

Phone*

Alternate Phone*

Key Holder?*

Yes

No

Miscellaneous Information

Alarm / Security Information

Alarm System in Place?*

Yes

No

Audible Alarm?

Yes

No

Alarm Company Name

Phone

Security Camera's in Place?*

Yes

No

Number of Camera's

Recording done:

Onsite Offsite

Location of Camera's

Safe Information

Safe in use?*

Yes

No

Type of Safe (floor, free standing, ect)

Location of Safe

Hazardous Material Information

HazMat on site?*

Yes

No

If answered yes, please explain:

Other Information

Any special instructions?