Automatic Detail Information Form

ROSCOMMON COUNTY CENTRAL DISPATCH
ENHANCED 9-1-1
AUTOMATIC DETAIL INFORMATION FORM

The 9-1-1 system will automatically display your telephone number and special conditions or instructions you provide to the Roscommon County Central Dispatch.

Please fill in the requested information below use ink only. The information you provide is critical in assisting local authorities to respond to an emergency at your location. ALL INFORMATION IS CONFIDENTIAL. All information is valid for one year and will require annual updates to continue validity.

If you are updating information that is already on file and you have a new phone number or address, please fill in the old information below.

Old Telephone No: __________________________________________________________

Old Address: _______________________________________________________________

Current Information:
Telephone No: ______________________________________________________________

Last Name: __________________________________ First Name: ____________________

Street Address: ________________________________________________ Apt #: _______

City: ___________________________________________ Zip Code: __________________

THIS ADDRESS IS A:

_____ House _____ Mobile Home _____ Farm _____ Business_____ Apartment
Landlord: _______________________________________________________________

THE FOLLOWING HAZARDOUS MATERIALS EXIST AT THIS ADDRESS:

_____ Gasoline _____ Diesel _____ LPG _____ Other Chemicals
_____ Ammunition _____ Explosives _____ Pesticides _____ Poisons
_____ Radio Active Materials _____ Watch Dog

Any other pertinent information: _____________________________________________________________________________________________

_____________________________________________________________________________________________

SPECIAL NEEDS PERSON AT THIS ADDRESS:

Last Name: ______________________________ First Name: ________________________ Date of Birth: ________________

_____ Hearing Impaired _____ Sight Impaired _____ Mentally Handicapped
_____ Alzheimer/Memory Impaired _____ Bedridden _____ On Oxygen Supply
_____ Physically Handicapped _____ Under Medical Care for Heart Problems
Other: _______________________________________________________________________________________

_____________________________________________________________________________________________

SPECIAL NEEDS PERSON AT THIS ADDRESS:

Last Name: ______________________________ First Name: ________________________ Date of Birth: __________

_____________________________________________________________________________________________

There is a Key or Keyholder located at:
_____________________________________________________________________________________________

_____________________________________________________________________________________________

Return this form to:
Roscommon County Central Dispatch
P.O. Box 87
Roscommon, MI 48653