Request for Dualcom

To guarantee next day delivery, please ensure that your order is submitted by 2pm.

* Required

NAME OF PERSON COMPLETING FORM AND EMAIL ADDRESS FOR CONFIRMATION

Title

First Name *

Last Name *

Email Address *

New Installation / Transfer *
New Installation
Transfer from ARC

If Transfer, from which ARC

If Transfer, please provide SIM / Data Numbers

SIM Number (Transfers Only)

Data Number (Transfers Only)

Residential / Commercial

Sleeping Risk

Reference / Purchase Order No - 12 Characters Max

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Product Type

Aerial Type

Delivery

Standard Signalling / Sia Signalling

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Delivery Address including postcode and contact details:-

Contact Name

Telephone Number

Email Address

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Customer Name

Address

Postcode

Site Telephone Number

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Police Response Required

Police Force

Intruder URN

P/A URN

Fire Brigade Response Required

Fire Brigade

Fire URN

Nimbus Fire Confirmation?

Please note that this is a chargeable extra.

Site Password

Duress Code

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Type of Verification fitted:-

Channel 1 – Type

Channel 1 – Contact Method

Channel 2 – Type

Channel 2 – Contact Method

Channel 3 – Type

Channel 3 – Contact Method

Channel 4 – Type

Channel 4 – Contact Method

Channel 5 – Type

Channel 5 – Contact Method

Channel 6 – Type

Channel 6 – Contact Method

Channel 7 – Type

Channel 7 – Contact Method

Channel 8 – Type

Channel 8 – Contact Method

Channel 9 – Type

Channel 9 – Contact Method

Channel 10 – Type

Channel 10 – Contact Method

Channel 11 – Type

Channel 11 – Contact Method

Channel 12 – Type

Channel 12 – Contact Method

Channel 13 - Type

Polling Fail

Channel 13 – Contact Method

Channel 14 - Type

Network Fail

Channel 14 – Contact Method

Channel 15 - Type

GPRS Fail

Channel 15 – Contact Method

Channel 16 - Type

Line Fault

Channel 16 – Contact Method

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Keyholder 1 Name

Keyholder 1 Telephone Number / Email Address

Keyholder 1 K/H Code

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Keyholder 2 Name

Keyholder 2 Telephone Number / Email Address

Keyholder 2 K/H Code

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Keyholder 3 Name

Keyholder 3 Telephone Number / Email Address

Keyholder 3 K/H Code

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Keyholder 4 Name

Keyholder 4 Telephone Number / Email

Keyholder 4 K/H Code

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Special Actions / Additional Information

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Remote Reset Fitted

Remote Reset - If yes select manufacturer

Alarm Installer

Company Code

Location / Chip No (If known)

Date

Name Of Person submitting this form

Terms and Conditions *
I Accept

I confirm that I am authorized to complete this request on behalf of the Alarm Installer. I / We understand that a binding contract shall be formed in accordance with the Terms and Conditions for the Provision of Monitoring Services

incorporated in the Credit Account Application Form which I / We submitted to EMCS and that this contract shall apply to all services referred to in the Application for Services from the earlier of:

a) the date that EMCS accepts this EMCS Request For Central Station Connection Form and b) the time that I / We first make a connection to the Communication Centre for the services referred to in this EMCS Request For Central Station Connection Form.

Prove you're not a robot *

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On completion of this form you will be taken to a confirmation page and given a case number for the request. If you do not receive this number, please contact our admin department.

EMCS

Request for Dualcom

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