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Provide Your Residential Emergency Information
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FOIA Request
Residential Emergency Information
Residential
Emergency Information and Contact Form
Please provide all of the requested information to allow us to provide optimal service to you and the occupants of your residence.
Residential Property Address
(Required)
Apt. or Unit Number
City
(Required)
Zip Code
(Required)
Your Name
(Required)
Your Cell Phone
(Required)
Your Email Address
What is your role?
Homeowner Resident
Renter Resident
Homeowner Landlord
Property Manager
Other
Your affiliation with the residence
Property Management Company
Property Manager's Phone Number
Name of the property owner
Property Owner's Phone Number
Is there an external key lock box?
Yes
No
Where is the key lock box located?
Is there a person not living in the residence who holds a key?
Yes
No
Keyholder Person #1
Cell Phone Number
Address
Zip Code
Is there another external person who holds a key?
Yes
No
Keyholder Person #2
Cell Phone Number
Address
Zip Code
Are there pets in the residence?
Yes
No
Pet types
Dog(s)
Cat(s)
Other
Dog type(s) and name(s)
Cat type(s) and name(s)
What type of animals are your pets?
Is there a swimming pool?
Yes
No
What type of pool is it?
In the ground
Above ground
Inside the home
Is there a privately-managed alarm system?
Yes
No
Alarm Company Name
Alarm Company Phone Number
Your Account Number
Reset Code
Reset codes are needed in the event that you are not home and we need to silence the alarm.
Where is the alarm panel located? (please be exact)
Is there a sprinkler system in the home?
Yes
No
Where is the water shut off for the sprinkler?
Are there any dangerous chemicals (other than normal household supplies) stored in your home?
Yes
No
Please list dangerous chemicals below (Name and approximate amount)
How many stories (not including the basement) is the home?
1
2
3
Other
Number of stories (not including basement)
Please enter a number from
4
to
20
.
Is there a basement?
Full basement
Partial basement
Crawl Space
None
OCCUPANT #1
Occupant #1 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #2
Occupant #2 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #3
Occupant #3 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #4
Occupant #4 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #5
Occupant #5 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #6
Occupant #6 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #7
Occupant #7 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #8
Occupant #8 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #9
Occupant #9 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
Are there any additional occupants of the residence?
Yes
No
OCCUPANT #10
Occupant #10 Name (first and last)
Birthdate
MM slash DD slash YYYY
Cell Phone Number
Where in the house does this person sleep? (include outside window location)
Does this person have special needs or disabilities?
Yes
No
Please describe this person's special needs
EMERGENCY CONTACT #1 INFORMATION
Name
(Required)
Relationship
Email Address
(Required)
Cell Phone
(Required)
Work Number
Home Number
Do you have additional emergency contacts?
Yes
No
Do you want to add any notes to this file?
Yes
No
NOTES
EMERGENCY CONTACT #2 INFORMATION
Name
Relationship
Email Address
Cell Phone
Work Number
Home Number
Do you have additional emergency contacts?
Yes
No
Do you want to add any notes to this file?
Yes
No
NOTES
EMERGENCY CONTACT #3 INFORMATION
Name
Relationship
Email Address
Cell Phone
Work Number
Home Number
Do you have additional emergency contacts?
Yes
No
Do you want to add any notes to this file?
Yes
No
NOTES
EMERGENCY CONTACT #4 INFORMATION
Name
Relationship
Email Address
Cell Phone
Work Number
Home Number
Do you want to add any notes to this file?
Yes
No
NOTES
Clicking Submit below will put the provided information on file with Pleasantview Fire Protection District until it is updated or deemed to be no longer applicable.
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