Emergency Notification List Form
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1Emergency Notification List
We need to reach you or your alarm responder in case of an emergency. In the order listed below, we will contact the
following people for notification upon an alarm/emergency:
Check one
st
1._________________________________________ 1
Phone {
Hm
Wrk
Cell
Alt} (
) ____________________________________________
Name
Check One
Check One
nd
2
Phone {
Hm
Wrk
Cell
Alt} (
) _________________________
3
Phone {
Hm
Wrk
Cell
Alt} (
) _____________________
rd
Email Address:_______________________________________________________________________
Check one
st
2.__________________________________________ 1
Phone {
Hm
Wrk
Cell
Alt} (
) ___________________________________________
Name
Check One
Check One
nd
2
Phone {
Hm
Wrk
Cell
Alt} (
) _________________________
3
Phone {
Hm
Wrk
Cell
Alt} (
) ____________________
rd
Email Address: _______________________________________________________________________
Check one
st
3.__________________________________________ 1
Phone {
Hm
Wrk
Cell
Alt} (
) ___________________________________________
Name
Check One
Check One
nd
2
Phone {
Hm
Wrk
Cell
Alt} (
) _________________________
3
Phone {
Hm
Wrk
Cell
Alt} (
) ____________________
rd
Email Address: _______________________________________________________________________
The following CODEWORD is to be used by anyone authorized to cancel an alarm activation or to make any changes with
an authorized person’s name and email address we will automatically set this service up for you to the above information.
Codeword: _ _ _ _ _ _ _ _ _ _ (up to 10 letters)
Bay Alarm Company offers Online Account Management (BayNet) to our active customers. Please provide us with an authorized
person’s name and email address we will automatically set this service up for you. If you are subscribing and paying for BayNetPlus
or E-Autolog the below information is required
Authorized Email Address :___________________________________________@___________________________
Authorized User’s Name: ____________________________________________________
**JURISDICTION: Fire Jurisdiction: ______________________________
City
County or OTHER
Does not apply
(check one)
Burglary Jurisdiction: __________________________
City
County or OTHER
UCSB Campus Police
(check one)
Authorized Signature:_______________________________________________________
SIGN HERE
Title:________________________________________________________ Date:________________
Emergency List Electronic 10/09
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