2. Form Information

   Providing this information allows the Athens-Clarke County Police Department to contact you in the event of an emergency (burglary, fire, unsecure door, etc.) after normal business hours. 

   Please update this information with any changes. If you have any questions, you may contact the Police Department at 706-613-3330.

4. Business Name / Resident Name
6. Business Name / Resident Name*
7. Phone Number*
9. Address*
10. Suite Number
12. Mailing Address
14. City*
16. State*
18. Zip*
20. Hours of Operation
22. E-Mail Address
24. Website
26. Emergency Contacts (In order of contact preference)
28. Name*
29. Mobile
30. Home
32. Name
33. Mobile
34. Home
36. Name
37. Mobile
38. Home
40. Name
41. Mobile
42. Home
44. Name
45. Mobile
46. Home
48. Name
49. Mobile
50. Home
52. Remarks
54. Additional Information (location of key or lockbox, gate code, relevant medical conditions, etc.)
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field