EMERGENCY NOTIFICATION SYSTEM OPT-OUT FORM by wuyunqing

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									                               LOWER PROVIDENCE TOWNSHIP
                                    100 PARKLANE DRIVE
                                   EAGLEVILLE, PA 19403
                             610-539-8020 610-539-6347 (FAX)



                      EMERGENCY NOTIFICATION SYSTEM
                             OPT-OUT FORM

The Lower Providence Township Emergency Notification System will be used to send vital
public safety messages via a phone call to residents and businesses. Completing this form
will remove your contact information from the system.



NAME:
              First                                                 Last


ADDRESS:


CITY:                                                    STATE:         ZIP:



PRIMARY PHONE NUMBER:

SECONDARY PHONE NUMBER:

ALTERNATE PHONE NUMBER:




I have chosen to opt-out of the Lower Providence Township Emergency Notification
System and understand that my contact information will be removed from the system.
Further, I understand that I will not receive any messages sent via the system.



Signature                                                                  Date




      LOWER PROVIDENCE TOWNSHIP EMERGENCY NOTIFICATION SYSTEM REGISTRATION FORM REV.   1/2008
        DATE:                         TIME:                         INITIALS:

								
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