1.  Application Information:
  * First Name:   
  * Last Name:   
  Date of Birth:   
  * Email:   
  Business Name:
  * Phone Number:        
* Alarm Site Address:         
  City, State Zip:    
  Mailing Address:      
  City, State Zip:    
2.  Building Owner (if different than Resident/Occupant/Tenant):
  Owner First Name:
  Owner Last Name:
  Mailing Address:      
  City, State Zip:    
  Phone Number:  
3.  Alarm Site:
  SiteType: Alarm Type:
  Rent/Own: Hours (if applicable)      to    
4.  Alarm Monitoring Company:
  * Company Name:
5.  Hazards (any special conditions or hazards at alarm site):

* Please review the following then check the boxes indicating your understanding.
The City of Dayton respects and is committed to protecting your privacy. We may collect personally identifiable information when you visit our site. We also automatically receive and record information on our server logs from your browser including your IP address, cookie information and the page(s) you visited. We will not sell your personally identifiable information to anyone.

Your payment and personal information is always safe. Our Secure Sockets Layer (SSL) software is the industry standard and among the best software available today for secure commerce transactions. It encrypts all of your personal information, including credit card number, name, and address, so that it cannot be read over the internet.

Refunds will be provided as a credit to the credit card used upon verification of the cancelled service. Credits will be issued on the same day as the verification of refund.

Web Payment Disclaimer

The City of Dayton, Ohio (“City”) is committed to providing its customers with the
highest level of service. In furtherance of this commitment, the City offers a program
allowing certain designated payments to the City by means of credit card or debit card
using the Internet.

Those who decide to pay designated liabilities to the City by credit card or debit card will
be asked to furnish personally identifying information. Any person using this website to
make payment agrees to voluntarily provide this information. The City will not rent, sell,
or otherwise make available to any third party any information that identifies a user or
payment made through this website, other than to process the transaction requested by
the user.

The City does not indicate a preference for any credit card or debit card service provider. The City does not: (1) endorse, recommend or require the use of any such companies or their products, processes, information or services; (2) make any warranty (express or implied, including the warranties or merchantability, fitness for a particular purpose and non-infringement) with respect to such companies or their products, processes, information or services; (3) make any representation with respect to such companies or their products, processes, information or services; (4) assume any legal liability or responsibility for any act or omission by such companies, or for the accuracy, completeness, timeliness or usefulness of any product, process, information or service offered by such companies.

In no event will the City be liable for any error caused by a user of this website, including but not limited to incorrect or incomplete account or property address information. To the fullest extent permitted by applicable law, the City disclaims liability for any and all damages, including indirect, special, incidental or consequential damages, including, but not limited to, damages for lost profits, disclosure of confidential information, or loss of privacy connected to the use, or inability to use, this website.

The City does not control any website referenced or accessed through links or otherwise from the City’s website. The City is not responsible for the content, privacy policies, security policies or procedures of such websites, or for the content, privacy policies, security policies or procedures of any links contained in such websites.

Only persons of legal age may use this website. Payment must be made in U.S. dollars.
The user of this website agrees not to make any payment that exceeds the funds or available credit line in the user’s account; if such payment or attempt occurs, the City has no obligation to complete the transaction and the user agrees the City may debit the user’s account for any returned item fee or other similar fee. The City is not responsible for not completing a transaction as a result of a limit placed by a user’s financial institution upon the user’s account. The City is not responsible if a financial institution fails to honor any debit against the user’s account. The City, in its sole discretion, may refuse to complete any transaction which it has reason to believe may violate any law, rule, or regulation, or if the City has reasonable cause not to honor it.

Communications to the City via any website, including the City’s website, shall in no way be deemed to constitute legal or official notice to the City, its agencies, officers, employees, representatives, or agents with respect to any existing, pending, or future claim or cause of action against the City or any of its agencies, officers, employees, representative, or agents where notice required by Federal, State or local law,.

This Disclaimer and all use of this website shall be governed and construed in accordance with the laws of the State of Ohio, without giving effect to rules thereunder pertaining to conflicts of laws.

The user of this website making or attempting payment agrees that any cause of action arising from use thereof shall be deemed to have arisen from a transaction of business in the State of Ohio and that the courts located in Montgomery County, Ohio, shall have exclusive jurisdiction over any such cause of action.

(RCGO 112)

By submitting this, you accept responsibility for payment of all fees or fines that may result from the operation on the alarm system serving the above alarm site.  Furthermore, you will surrender this permit if I transfer ownership of the alarm site property.