Premise Info Request

I. Requesting Party’s Information

Name of Requesting Party *

First

Last

Contact Phone Number *

Contact E-mail Address *

Requesting Party's Address *

Address Line 1

City

State

Zip Code

II. Premise Information

Premise Address *

Address Line 1

City

State

Zip Code

Name of Resident(s): *

First

Last

Phone Number(s): *

Information to be Maintained: *

Reason for Request: *

Duration for Request (if known):

Requester’s Relationship to Resident (if not the resident):

III. Authorization and Release

I authorize the Charlottesville – UVA- Albemarle Emergency Communications Center (the “ECC”) to maintain the information contained in this record (“information”) in its 911 call center database and to share this information with law-enforcement officers, emergency medical services providers and any other individuals as needed for the provision of emergency services at the address listed in Section II. I agree that the ECC owes no duty to maintain or disclose this information and will purge it within one (1) year of the date below. I release the ECC and all of its agents and employees from any and all liability for personal injuries, including death, and property damage that may arise from the use or disclosure of this information and further agree to indemnify and hold harmless these parties from any legal claim or suit arising from such use or disclosure.

Signature of Requesting Individual *

Date / Time *

Signature of Resident (if different from above)

Date / Time

ECC Premise Information Request Form For the Public

I. Requesting Party’s Information

II. Premise Information

III. Authorization and Release