by U.S. Computing © 2009

Report Date: 8/17/2017
GENERAL INFORMATION
 
Resident:
Or  
Last Name First Name Middle Name
Business:
Street Number:   Prefix: Street Name:   Type: Suffix:
City:   State: Zip:  
Name & Street Address of Apartment Complex or Mobile Home Park: Apt #/Lot #:
Description of Premises:
Phone Number:     xxx-xxx-xxxx Email:  
Are you participating in the Vial of Life program?   (If yes, please check where it’s located.)
If you would like to participate visit www.lex-co.com or call 785-2366
SECURITY/KEYHOLDER INFORMATION
Is there an alarm system on the premises?   (If yes, please give the name and phone number of the alarm company below.)
Company Name: Phone: xxx-xxx-xxxx  
   
EMERGENCY CONTACT(S) SHOULD BE IN THE LEXINGTON COUNTY/COLUMBIA AREA
Name:
Relation: Daytime Phone:   Evening Phone:  
Name:
Relation: Daytime Phone:   Evening Phone:  
HEALTH AND SAFETY INFORMATION
Do any persons with special needs live on the premises?   (If yes, please explain below.)
 
Are there any dangerous substances/materials on the premises? (explosives, corrosives, highly flammable material, etc.). If yes, please list material(s) and detail the storage location & amount of material.  
 
Are there any animals on the premises which someone might consider aggressive?   (If yes, please explain below.)
 
By the submission of this information and be signing below, I understand and agree that the Lexington County Sheriff’s Department, Lexington County Fire Service, Lexington County EMS, and the County of Lexington neither warrants nor guarantees the safety or security of my property or family. This information is merely provided for whatever ancillary benefit that may be created. Further, I release, agree not to sue, and hold harmless the Lexington County Sheriff’s Department, the Sheriff, his deputies, agents, assigns, Lexington County Fire Services, Lexington County EMS, the County of Lexington, Lexington Medical Center and others similarly situated from any and all liability associated in any way with the provision of this information or related provision of services.
Signature: