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� . , RESIDENTIAL SERVI�ES CONT�� InIIIIIIIIIIIIIIIINIIIIIUIIInI�i�I�IIIiNI <br /> 5104UE12 <br /> CONTRACT�����j CUSTOMER JOB /��/ LEAD� <br /> DATE � IC�,CJ� l�J ACCOUNT NO NO �J/J SOURCE <br /> • � • <br /> O Check received for. O Installation: Check N Amount � <br /> O Annual Service Charges Collected: Check # Amount � <br /> I authorize ADT O To withdraw all Service Chargesfrom my bank accou�rt O To charge my aeditldebit card for. <br /> O Annually O Semi-Annually O Quarterty O Monthly O Installation O 3 monthly aediVdebit card paymenu of equal amounts <br /> Ghoose one: O Checking O Savings (available only for telephone orders with an installation price <br /> Name of BanWCredit Union <br /> over 5400 or field sales with an installation price over 51,500) <br /> O All/Recurring Service Charges <br /> O Annually O Semi-Annually O Quarterly O Monthly � <br /> ABA Routing Nurr�er Bank Account Number O VISA O MasterCard O Discover O AMEX <br /> CrediVDebit Card Number Expiration Date <br /> Recurcing Service Charge Amou�t � M M Y Y <br /> Name as it appean on bank account Recurring Service Charge Amount � <br /> Cardholder's Name <br /> � <br /> I authorize ADT`�o debit my bank account for tfie amouM of all Recurring Service Charges H I am using a debit catd, I authorize ADT to debh my bank account for the amount of <br /> indicated abave. I may revoke this authorization only by notifying ADT and my bank in all Recurring Servite Charges indicated above. I may revoke this authorization only by <br /> writing atJeast 10 business days before the scheduled debit noti(ying ADT and my bank in writing at least 10 business days before Me scheduled debit. <br /> If no oval is filled above, service charges wili be withdrawn monthly. If rro oval is filled above, my credit/debit card will be charged monthly. <br /> I aut}wrize ADT to withdraw the amounu in this section from my bank account or aedit card through an Automated Clearing House ('ACH'). These paymentr are for the equipment and <br /> services desaibed in this Contract This authorizatlon will remain in effect until ihe terminatian date of ihis Contract or until I oncel it in writing, whichever aars first I also agree to <br /> notify ADT in writing of arry changes in my account infortnation at leart 15 days prior to the next billing date. If a payment date falls on a weekend or holiday, payment may be executed on <br /> the next busineu day. Because this is an electronic traraaction, these funds may be withdrawn from my account each rtwnth as early as the transaction date. If ihe date or amouM ot the <br /> withdrawal changes, ADT wili notify me at least 10 days prior to the payment being collected. If an ACH transaction is rejected for non-suffident funds (NS�, ADT may attempt to process the <br /> diarge again within 30 days, and an NSF diarge may apply. The originaeon of ACH transactions to my account must cnmply with the provisions of U.S. law. l am an authorized user of this <br /> aedit card or bank account, and I will not dispute the paymerrt with my cmdit card company or bank, so long az the amount corresponds to the 4erms indicated in this Contract <br /> C� To send me a bill: O Mnually c�SSemi-Annually O Quarterty O Other DOA Approvaf If no oval is filled, ADT will send hill quarterl ^ <br /> Authorized Account Signature: ` � <br /> • • • �. <br /> Name <br /> CS # <br /> Address <br /> City State� ZIP 't3�! Cross St. <br /> Premises' Phone #1 J Phone Yk2 Q/Cell Only <br /> Municipality Municipality <br /> Police Name Fire Name <br /> Municipality Patrol Name <br /> Medical Number & Number � <br /> Job Type �New Sale Change O�ver Upgrade Control Type O HW � RF <br /> Affiliation ,�a�� � Member# ��7 ��,� /��'J� Permit <br /> � Number <br /> Burglar Alarm: �1Yes O No Fire / Smoke: O Yes c� No Two-Way Voite: �Yes O No Cellular Model: O Parallel O Sundard I <br /> � <br /> �'P"r`o'file ���`�' � �,�7 = ''- Pfeferred Monitorin` Communicatiom Aecount Manag'pment <br /> COdES: Ownership i n� System � Service Ll1�l Services � Method � Services � � <br /> Guard Market Resale-Former <br /> ELW/QSP. Service � Group� Acct # Former CS # <br /> • • • • <br /> This password must be issued to all users of the alarm rystem, including all people lis[ed in Section 7 An optional, secondary password for service individuals, housekeepers, tenanu, <br /> etc. is available upon request. A password must be no less than three (3) and no more than five (5) characters in length and may not contain any punauation or spaces, otfensive <br /> language or non-s[andard spelling. Customer may change passwords and cuntac[s by going to www.MyADT.com or by calling ADT toll-free a[ 1.SOO.ADT.ASAP <br /> • •' • <br /> These are the individuals who may be called in the event of an alarm. Because they may need to meet the auihorities in response to an alarm, I will provide them access to my premises, <br /> the password, and the keypad code. By seleRing ihe "Yes" designation on the rigAt I am identifying which of.tliesS� dj�i �II Q�� �cation of�e authoriti� <br /> Customer/Emergency Contact #7 `� y� II /I�� - ��� �� � � � Q <br /> Pnnt FirsULast Name �� �� l Phone <br /> Home Cell Work Yes No <br /> �/�. � — f�8 8 O O C�J O <br /> Phonew i � Home Cell Work Yes No <br /> CustomerlEmergency Contact #2 /� �-7 �"� /1� �' O O O CaJ <br /> Print FirsUlast Name � �j Phone �/ � ry Home Cell Work Yes No <br /> o � o o � <br /> Phon �� Home Cell Work Yes No <br /> AltematelEmergency Only ContaR "" � O O O O O <br /> Print FirsULast Name Phone' Home Cell Work Yes No <br /> � O O O O O <br /> Phone Home Cell Work Yes No <br />