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2. Registrant Information
4. First Name
5. Last Name
7. Property is:*

   1. Business
   2. Resident
9. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Please confirm that you would like to opt out of the program:*

    1. I request to have my information and camera registry removed from the Denison Police Department’s database.
18. Reason for Opting Out (Optional):
20. Acknowledgment

    By submitting this request, I understand that my camera information will be removed from the registry and will no longer be accessible for law enforcement purposes.

22. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature
25. Date
    Date
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field