Business Emergency Information Request Form

* Required items

The Communications Department, in conjunction with the Currituck County Sheriff’s Office, requests the following information from your business to be used for emergency purposes only. This information will be used by the county to alert you of events or situations that could or have affected your business establishment. Without the business information the county’s ability to contact you in a timely manner may be delayed. Business Information
* Name:
* Owner:
* Physical Address:
Physical Address:
* City:
Phone numbers must be numbers only. Ex. 2525555555.
* Business Phone
Phone Extension
Email Address
Hours
Monday Open:
Close:

Tuesday Open:
Close:

WednesdayOpen:
Close:

ThursdayOpen:
Close:

FridayOpen:
Close:

Saturday Open:
Close:

SundayOpen:
Close:
Nearby Landmarks
Nearby Landmarks: General reference to objects around your business.
Cross Street 1: Indicate if your street crosses or intersects with another street.
Cross Street 2: Indicate if your street crosses or intersects with another street.
Directions: Give a brief description of directions to your business.
Alarm Company
Name:
Phone numbers must be numbers only. Ex. 2525555555.
Phone Number:
Contact Information List at least two contact names. The contact person should be a “key holder” or a person who can access the building in the event a response is needed from the business establishment.
Contact One
Name:
Phone numbers must be numbers only. Ex. 2525555555.
Phone Number:
Cell Phone Number:
Alternate Phone Number:
Contact Two
Name:
Phone numbers must be numbers only. Ex. 2525555555.
Phone Number:
Cell Phone Number:
Alternate Phone Number:
Contact Three
Name:
Phone numbers must be numbers only. Ex. 2525555555.
Phone Number:
Cell Phone Number:
Alternate Phone Number:

Comments:

Enter the security code.

Business Emergency Information Request Form

Business Information

Hours

Nearby Landmarks

Alarm Company

Contact Information