Alarm Packages (Please Select One)



Alarm w/ Remote Phone Access/Text Message Capability (Install Fee $160.00 | Monthly $45.00)

Cellular Communication with Text & Email Notification (Install Fee $500.00 | Monthly Fee $61.00)

Basic Alarm with Cell Backup (Install Fee $450.00 | Monthly Fee $45.00)

Farmers Insurance Special

Service

($125.00)
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Customer Basic Information ( * Required in Red )

*First Name:
*Last Name:
*Customer E-Mail Address:
*Customer Phone Number:
Building Type:
*Address:
*City:
*County:
*State:
*Zip:
Other Information and/or Directions:
Cross Street:
Preferred Installation Date:

Emergency Information

*Customer Abort Code (A Word or Phrase):
1st Emergency Contact If Away From Premise:
Phone #1:
Phone #2:
2nd Emergency Contact If Away From Premise:
Phone #1:
Phone #2:
3rd Emergency Contact If Away From Premise:
Phone #1:
Phone #2:
4th Emergency Contact If Away From Premise:
Phone #1:
Phone #2:

Billing Information

*Credit Card Type:
*Credit Card Number:
*Credit Card Security Code:
*Name on Credit Card:
*Expiration:
(MM/YY)
*Credit Card Billing Address:
*Credit Card Billing City:
*Credit Card Billing State:
*Credit Card Billing Zip:

I confirm that all information in the above fields have been verified and are correct.

I authorize TL Polk Industries & Cornerstone to process my credit card for the purchasing of alarm equipment and / or monthly billing. All cancellation will be sent it by email to info@tlpolkindustries.com or faxed to TL Polk Industries at 877-857-6552.

I acknowledge that upon Cellular Communication cancellation, access will be provided to deactivate the Communicator.

Copyright © 2011. TL Polk IndustriesInc. All Rights Reserved.