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2. Emergency Contact Information - Police
   Please assist the City by providing the following information. This information is used by the Casselberry Police Department for contacting key personnel in case of an emergency.
4. Submit
   Please complete the information sections below and submit the request online. Alternatively, the below form can be printed and brought or mailed to the Casselberry Police Department located at 4195 South U.S. Highway 17/92, Casselberry, Florida 32707.
8. Business Information
10. Name of Business*
12. Business Address*
14. Suite or Apartment Number
16. City*
17. State*
18. Zip*
20. Cross Streets
22. Shopping Center Name (if applicable)
24. Business Phone Number*
25. Email Address
    Under Florida law, email addresses are public records.
27. Property Manager
31. Emergency Contacts
    After Hours Contact Name(s) and Number(s)
33. Name*
34. Phone Number*
36. Name
37. Phone Number
39. Name
40. Phone Number
44. Alarm Information
46. Alarm Company
47. Phone Number
51. Additional Information
55. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
57. Electronic Signature*

    1. I agree.
59. Signature*
60. Date*
    Date
62. Email Notice
    Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public-records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field