SOUTHAMPTON VILLAGE POLICE DEPARTMENT
151 Windmill Lane
Southampton, New York 11968
EMERGENCY PREPAREDNESS INFORMATION
This form is intended to collect
required to assist Police, Fire, and Ambulance personnel when responding to your home or business in the event of an emergency. Please take the time to complete the entire form before you submit it. When you have finished filling out the form click the submit button located at the bottom of the form. Your emergency responders appreciate your cooperation in performing this invaluable service.
PLEASE REMEBER TO ANSWER ALL QUESTIONS
TYPE OF LOCATION:
BUSINESS / RESIDENCE NAME:
PROPERTY OWNERS NAME:
Emergency Contact Person(s):
Who will respond with a key in the event of an emergency? It is highly recommended using someone that can respond within 15 minutes.
Provide your contractors name and telephone number that performs these services:
Elevator Serv. Co:
Fuel Oil Co:
Furnace/Boiler Ser. Co:
Generator Serv. Co:
Guard Serv. Co:
Propane Del. Co:
BUSINESS RESIDENCE LOCATION INFORMATION:
How long has your business/residence been at its present location?
My Business / Residence is on the
– Side of the Street.
of (Cross Street)
Other descriptive features about your home/business that would help responders locate it in an emergency:
Nearest fire hydrant location:
of the premise.
Please check all that apply for the above property:
Narrow Driveway (< 12ft)
Height Restrictive Driveway (< 12ft)
Fire Sprinklers / ANSUL System
Pets Located Inside Premise
Property Located on a Flag Lot
Metal Hurricane / Riot Doors
Third Floor Living Space
Hazardous Materials Stored Outside
Tempered Hurricane Windows
Barricade Type Bars on Door(s)
Guard Dog on Premise / Property
Anti Theft Window Bars (Ground Floor)
Do you have firearms or reloading supplies on the premise?
If YES please list all in COMMENTS box below.
If applicable - Driveway Gate Code (
For Emergency Responders Only)
Do you have a KNOX Box at your location?
If YES where is it located?
If NO information about Knox Boxes and other Knox Rapid Entry System products can be found at
Are there any occupant(s) with Special Needs that reside or frequent your home or business?
Please check all that apply:
Does an occupant require a wheelchair or walker for mobility?
Does an occupant require oxygen or special life support equipment while at home?
If required to evacuate during an emergency,
will the occupant with special needs require any special equipment, medications, medical personnel or transportation?
If YES please explain the needs and special instructions:
Please make sure that you have filled out the above form correctly before submitting it.