TL Polk Industries Inc. - New Customer Entry Form

Alarm Packages (Please Select One)

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

Transfer My Service ($125.00)
Where are you transferring from?

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 [email protected] 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.