Business Security / Contact Form

The following information is requested annually from local businesses. This information is used in the event Massillon Police or Fire Departments need to contact someone after hours for an emergency such as a break-in, vandalism or fire.

This form is intended for official police use only. All information submitted will be kept confidential.

Fields marked with an * are required

Business Security/Contact Form

Name of Business *

Street Address *

Address Line 2

City

State

Zip Code

Normal Business Hours

Phone Number *

Fax Number

After Hour Emergency Contacts — First Contact

• If you have no changes in contacts, please check the box

No Changes

Name *

First

Home Address

Home Address Line 2

City

State

Zip Code

Phone Number

Cell Number *

After Hour Emergency Contacts — Second Contact

Name *

First

Address

Address Line 2

City

State

Zip Code

Phone Number

Cell Number *

After Hour Emergency Contacts — Third Contact

Name

First

Address

Address Line 2

City

State

Zip Code

Phone Number

Owner of Business

Name *

First

Address

Address Line 2

City

State

Zip Code

Phone Number *

Owner of Building

Owner of Building Cell Phone

Comments or Security Concerns

Email Address

Captcha

If you are human, leave this field blank.

Business Security / Contact Form