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COMMENTS AND CLARIFICATIONS Note: Clarify location or area of coverage, as needed.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

AREA COVERED Note: Buildings, Floors or Area(s) should be listed here ______________________________________________________________________________

______________________________________________________________________________

Type (Circle One)

NFPA (Circle One)

Edition Year

Central Station

NFPA 71 or NFPA 72

__________

Local

NFPA 72 or NFPA 72A

__________

Auxiliary

NFPA 72 or NFPA 72B

__________

Remote Station

NFPA 72 or NFPA 72C

ALARM SYSTEM DESCRIPTION SYSTEM TYPE System Type: System is installed and maintained in compliance with Standard identified.

Authority Having Jurisdiction, i.e., Requiring Certification (List Below):

Proprietary

__________

NFPA 72 or NFPA 72D

__________

______________________________________________________________________________

Responding Fire Department (List Below):

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

/ / (mm/ dd / year) Date of Periodic Test Agreement: _____ ______ ______ * Please note a testing and maintenance contract date is required.

© 2012 UL LLC

2 – Revised 05/21/2007

UL Form No. CS-ASD-FAS

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