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REMOTE MONITORING Monitoring Location: (Circle only one. Choose from UL Listed Central Station, Fire Department, Proprietary, Other or No Remote Monitoring). Indicate your choice by

circling the appropriate form of monitoring.

UL Listed Central Station

F i l e N u m b e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Service Center Number:

_________________

Company Name:

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

City, State and Zip Code:

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

Fire Department Dispatch Center

Name:

_______________________________

(Use Address box at right)

Proprietary Supervising Station (Use Address box at right)

Address:

_____________________________

Other Location As Approved by AHJ

City, State and Zip: ____________________

(Remote Stations only) (Use Address box at right)

Alarm Retransmission Method to Fire Department: Primary

Secondary

Code Transmitter Direct Telephone Line Public Telephone Network Private Communication System 911 Emergency Services

______ ______ ______ ______ NA

______ ______ ______ ______ ______

No Remote Monitoring (Local Systems)

© 2012 UL LLC

6 – Revised 05/21/2007

UL Form No. CS-ASD-FAS

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