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CORTLAND COUNTY DEPARTMENT OF EMERGENCY RESPONSE AND COMMUNICATIONS 54 Greenbush Street ~ Cortland, New York 13045 Phone [PHONE REDACTED] ~ Fax [PHONE REDACTED] Emergency Contact Information Sheet Directions 1) Download (Save) the form to your computer 2) Close the web browser 3) Open the File you saved using Adobe Reader 4) Fill out the form in entirety and save 5) Email the form as an attachment to [EMAIL REDACTED] ---PAGE BREAK--- CORTLAND COUNTY DEPARTMENT OF EMERGENCY RESPONSE AND COMMUNICATIONS 54 Greenbush Street ~ Cortland, New York 13045 Phone [PHONE REDACTED] ~ Fax [PHONE REDACTED] Emergency Contact Information Sheet Date of Information: Business Name:_ Phone:(_ ) D.B.A.: Address: Business Owner (if applicable) : Property Owner (if known): Name: Name: Address: Address: City: City: State: State: Zip: Zip: Phone 1: Phone 1: Phone 2: Phone 2: To be notified in case of an Emergency: 1st Name: Title: Key Holder: □Yes □No Home Phone: Cell Phone Address: City, State Zip: 2nd Name: Title: Key Holder: □Yes □No Home Phone: Cell Phone Address: City, State Zip: 3rd Name: Title: Key Holder: □Yes □No Home Phone: Cell Phone Address: City, State Zip: 4th Name: Title: Key Holder: □Yes □No Home Phone: Cell Phone Address: City, State Zip: ---PAGE BREAK--- Business Information: Number of Employees: Number of shifts: Business Type: (Restaurant, manufacturing, retail, etc) Square footage: Number of Exits: Number of floors: □ Basement: Does your business or property have any of the following? (Please check all that apply) Law Enforcement □Surveillance/Security Video □Security Guards □Is building alarmed for burglary, intrusion, panic… □K9 on Premises Local Alarm □Yes □ No □Lights on Timers/Intentionally Left on Regularly Direct Tie In With Company □ Yes □ No □Video Surveillance Alarm Company Alarm Company Phone Number Location of Alarm Panel Fire Service □Fire Alarm System □Knox Box Location of Fire Alarm Panel Location of Knox Box_ □Fire Department Connections Gas Shut Off Location Location of FDC Fuse Box Location Sprinkler System: □ Yes □ No □Elevators Please list any specific hazards (such as the location of stored flammable liquids, etc.): Person completing form: Telephone: