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UL LLC

333 Pfingsten Road, Northbrook, IL 60062-2096 Phone: (877) UL HELPS, Fax: (847) 407-1001

SN:

Fire Alarm System Description Worksheet

PROTECTED PROPERTY

N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Address:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

City: ____________________ State:

________

Zip Code:

___________________

Representative Name (please print): ________________________________

ALARM SERVICE COMPANY

File No:

Service Center Number:

_____________________

__________________

Name: ________________________________________________________________________

Address:

______________________________________________________________________

City: ____________________

State:

_________

Zip Code:

_________

Representative: Name (please print): __________________ Representative Title (please print): ____________________

Phone Number:

(

) ____________________

Fax Number:

(

) ____________________

PERIOD OF ISSUANCE Note: Issue date must be within the last 30 days or request can’t be processed. Certificates may be issued from 1 to 5 years.

Issue Date:

/

/

___ ___ ___

Expiration Date:

___/____/___

O l d S e r i a l N u m b e r ( I f a p p l i c a b l e ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

New

________

Renewal

_________

Replacement

__________

© 2012 UL LLC

1 – Revised 05/21/2007

UL Form No. CS-ASD-FAS

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