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For all municipal business license questions, contact: City of South Bend • Department of Community Investment 215 S. Dr. Martin Luther King Jr. Blvd. • Suite 500 South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021 LICENSE APPLICATION FOR - ALARM AGENT MUNICIPAL CODE SECTION - 4-18.7 (SEE ALSO 12.1-12.6) IV. CONTACT PERSON A. Contact Person's Legal Name: B. Residential Address: City: State: Zip: C. Residential Telephone Number: D. Cellphone Number: E. Position with Organization: V. DO NOT SEND THE FOLLOWING INFORMATION TO THE CITY OF SOUTH BEND UNTIL REQUESTED. Applicant, by submission of this application, agrees to maintain the following records and to provide them to the South Bend Police Department or South Bend Fire Department immediately upon request. A. Maintain and provide immediately upon request to South Bend Police or Fire Departments: records of current alarm users employing applicants services, including name, address, and telephone number of location where alarm system is installed, as well as names, addresses, and telephone numbers of primary, secondary, and any additional key holders of that alarm user. B. If facility has multiple alarm systems or sensors, maintain facility floor plans, blueprints, or similar documents showing zone locations for each system or sensor. VI. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION VII. AFFIRMATION I, hereby, certify and affirm that all of the information I have given in this application is true and accurate to the best of my knowledge. I further certify that I have in no way attempted to mislead the City in this application by omitting facts known to me. I have read and understand the regulations of the Alarm Agents license found in the City of South Bend Municipal Code, Sections 4-18.7, 12-1, 12-2, 12-3, 12-3.5, and 12-6. Signature Date