Dealer Information Form

Please type or print and return to
SECURITY CENTRAL along with the
Dealer/Installer Contract.
Billing Information
Company Name:
.
Owner’s Name:
.
Owner’s SS#:
.
Mailing Address:
.

.
City:
  _____________________________________
. .
  _____________________________________
. .
  _______________________D.O.B.: _______
. .
  _____________________________________
. .
  _____________________________________
. .
  __________________State:____Zip:_______
Indicate Preferred Billing
[ ]  
.  
..
[ ]  
.
[ ]  
.
.
[ ]  
.
[ ]  
Annually
            (Accounts paid annually receive
             a one month discount)
Semi-Annually
.
Quarterly
[ ] Keep in same quarter
. .
Monthly
. .
Bill Directly to Subscribers
Shipping Information
Company Name:

Attention:

Mailing Address:



City:
  _____________________________________
.
  _____________________________________
.
  _____________________________________
.
  _____________________________________
.
  __________________State:____Zip:_______
Business/Tax Information
  
[ ]  
[ ]  
[ ]  
[ ]  
  
Organization is:
Corporation
Partnership
Individual
Other: _______________________________

If purchasing equipment, please provide your Tax ID Number below.
Tax ID Number: _______________________
Contact Information
Security Central would appreciate a responsible individual from your company be reachable 24 hours a day!
Office #:

Fax #:

Pager #:

Cell #:

______ #:
   (_______) _________________________
.
  (_______) _________________________
.
  (_______) _________________________
.
  (_______) _________________________
.
  (_______) _________________________
...

Notification on
Subscriber Alarm Activations

[ ] No notification needed
[ ] Notify via email at the time of alarm activation at the following email address :________________________
[ ] Notify via FAX   [ ]Daily   [ ]Weekly   [ ]Every 31 days
[ ] Notify via mail   [ ] Weekly   [ ] Every 31 days
Dealer Authorization List
If you wish to use a single passcode for use by your entire organization to access records at Security Central,
please enter it here.
Passcodes may be up to 12 characters in length.

Company Passcode: _______________________________

If you would prefer that members of your organization identify themselves with individual passcodes to access records at Security Central, please list them here.
Name

_______________________

_______________________

_______________________

_______________________

_______________________

 Passcode

____________________

____________________

____________________

____________________

____________________
Security Central         (800) 438-4171 / (704) 838-8000    Fax: (704) 838-8050