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Diebold Event Monitoring Center
New Site Information Form
Diebold EMC must receive this form 48 hours before site is expected to receive monitoring service. Failure to provide the fully
completed and executed form within such time frame may result in a delay in the performance of one or more of the Services.
This New Site Information Form ( "New Site Form ") is entered into by and between Diebold, Incorporated ( "Company ") and the
Subscriber whose name is set forth below. When used herein, (i) capitalized terms not otherwise defined in this New Site Form shall
have the meanings set forth in the Diebold Event Monitoring Center Master Security Services Agreement by and between Company
and Subscriber (the "Master Agreement "); and (ii) "Site" shall have the same meaning as "Premises" in the Master Agreement. This
New Site Form is incorporated into, and forms an amendment part of, the Master Agreement.
Sales Rep. Name: Robert Chapin Diebold Site #:
Business Name (Subscriber): City of Oak Park Heights Alt Name or Number:
Street Address: 14168 OAK PARK BLVD N Nearest Cross Street:
City: Oak Park Heights State: MN Zip Code: 55082
Business Phone #: (1) 651 - 439 -4439 (2)
Billing Address (If different):
City: State: Zip Code:
Site Information• I * *Mouse over select for the description.
Alarm Panel Manufacturer: Pacom
Type of Installation: Government
Type of Primary Communications: Network
Type of Backup Communications: Phone Line
Access Control: No
Video Monitoring: No
IMPORTANT - To reduce false alarm fines, the EMC has implemented a two call verification on all burglary zones.
Events and Responses: Fill in the response instructions below for the events EMC will monitor at this location.
Event Response Instructions
Fire Fire Dept, Site, Call List (FSC) I * *Mouse over select for the description.
Duress Police, Call List (PC)
Holdup Police, Call List (PC)
Burglary Site, Call List, Police (SCOP)
Supervisory Call List Only (CO)
Trouble Call List Only (CO)
Panel Test Not Received Call List Only (CO)
Access Door Propped -- Select --
Video -- Select --
Two Way Audio Script
Other
Page 1 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
Local Agencies: (Fill in the agencies that apply to your response plans)
Fire Department: Name: Bayport Fire De Phone #: 651 275 - 4401
EMS Name: Phone #:
Guard / Security Center Name: Phone #:
Police Department Name: City of Oak Park Heights 651 439 - 4723
Phone (NOT 911) #:
Police Alarm Permit Number: Type: Exp. Date:
(If not known please check with the local jurisdiction or Diebold can provide this service for a fee.)
Authorized Individuals: Security Officer; After Hour Key Holders; Individuals able to verify alarms; Cleaners, Vendors
Corporate Security Officer's Name: Eric Johns Title: Administrator
Mail Address: p.o. box 2007, Oak Park Heights, MN 55082
Email Address: eajohnson @cityofoakparkheights 651 439 -4439
Work Phone #:
Cell Phone #: 651 253 -7837 Home Phone #:
List names of all contacts to be called to verify alarms or discuss security issues. After -hour contacts will be called by the
order they are entered below. Personal Identification Numbers will be mailed to individuals at site, unless otherwise
instructed in the comments section.
Authority Levels
There are three levels of authority for persons on Subscriber's behalf (collectively, the "Authority Levels "). Each Authority Level
authorizes a person to perform one or more tasks. The Authority Levels consist of the following:
Level One. Lowest authority level. Provides view only access to Revisor On -Line, which permits viewing of Premises - related
information. Includes on call list for notification of alarm conditions at Premises and authority to cancel alarms. Authority to place
alarms on test for no more than 8 hours.
Level Three. Intermediate authority level. Includes all of Level One plus authority to request temporary changes through
Revisor On -line and to place zones on test for up to four days. Generally on after hours call list.
Level Four. Highest authority level. Includes authority to bind Subscriber to contracts with Company. For Revisor, this level of
authority can make changes to Premises related information, place zones on test up to fourteen days and full access to Revisor On-
line. These persons are referred to in the agreement as a "Level Four Security Executive."
Authority After -Hours
Name Level Contact Title Type / Phone Number Email Address
Eric Johnson 4 Yes President / CEO Cell 651 253 -7837 eajohnson @cityofoakparkheightst
Andrew Kegley 3 Yes Security Officer Cell 651 775 -5759 akegley @cityofoakparkheights.com
Brian DeRosier 3 Yes Security Officer Cell 651 485 -2307 bwderos @cityofoakparkheights.cti
Gary Brunckhorst 3 Yes Security Officer Home 715 386 -1064 gbrunckhorst @cityofoakparkheigla
Andrew Kegley 3 Yes Security Officer Cell 651 334 -5140 akegley @cityofoakparkheights.com
-- Select --
-- Select --
-- Select --
Page 2 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
-",'7
Normal Hours of Operation: Holidays Closed: Closed federal holidays? E Yes ❑ No
Day Time Open Time Close Other Dates: Time Open Time Close
Monday 8:00 AM 4:30 PM 11/29/2013 Closed Closed
Tuesday 8:00 AM 4:30 PM 12/24/2013 Closed Closed (After hours
response plans
Wednesday 8:00 AM 4:30 PM Click To Select followed on these
Thursday 8:00 AM 4:30 PM Click To Select dates)
Friday 8:00 AM 4:30 PM Click To Select
Saturday Closed Closed Click To Select
Sunday Closed Closed Click To Select
Supervised Open/Close: (If this priced option has been chosen, please fill in the data below)
Opening may occur minutes before normal open or minutes after normal open.
Closing may occur minutes before normal close or minutes after normal close.
Response Plan: E{ Site, Call list; Police (SCOP) ❑ Guard/Security Only (GO) 0 Call List Only (CO) ❑
Other:
Revisor Online:
Do you currently have access to Revisor Online? No If no, please go to our web site to request access:
http://securitymontoring.diebold.com
Diebold Revisor Online is a free, secure intemet access that provides Diebold Event Monitoring Center customers with the ability to view and perform certain
administrative functions with their monitored sites, at their convenience, from any PC with a web browser. Revisor Online is used to submit change requests, view
account activity, place accounts on and off test, and generate reports. Revisor Online promotes an efficient and consistent method to verify the security of your
operation.
Comments:
By signing below, I represent and war it th ,' (i) a Level Four Security Executive (as defined above); and (ii) fully authorized to bind Subscriber to
the terms of the Agreements inclu g is . e Information Form. This New Site Information Form may be executed and delivered by facsimile or
electronic mail as provided in • a er • : e . The Services provided at the Premises as reflected in this New Site Form are subject to and governed
by the Agreements.
Authorized Signatur :
Continental US
Name: IC, c) PSt. / Diebold /EMC
(� •t) 3800 Tabs Drive
Title: C � 0,14 4428 -. Dept. 8317 -S
Uniontown, Ohio 44685
I Z2 J J� Fax: (330) 498 -2888
Date:
Hawaii / Guam / Saipan
Diebold / EMC
Contact your Diebold Service provider to activate and test monitoring services for this site. 3375 Koapaka St.
Diebold Service can be reached at 1- 800 - DIEBOLD (800- 343 -2653) Suite B270
Honolulu, Hawaii 96819
If you have questions or concerns, please contact the Diebold Event Monitoring Center at Fax: (808) 837 - 6458
1- 800 -548 -4478, Option #5, or send an email to the Care Team. emcctr(a,diebold.com
Page 3 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
Site Information Form — Reference Sheet
A Diebold Event Monitoring Center Master Agreement must be
on file before submitting the Site Information Form.
1. Sales Rep. Name: Diebold sales representative's name is entered here.
2. Diebold Site #: If known, enter assigned nine digit Diebold site number.
3. Business Name: Name of business (matching master agreement) being monitored at this location.
4. Alternate Name or Number: All corresponding alternate site/branch names or numbers.
5. Street Number and Name: Enter physical address of location being monitored for dispatching authorities.
6. Cross Street: Enter name of closest cross street (intersection) that will be used to assist local authorities to find location.
7. City, State, Zip Code: Of site address.
8. Business Phone #: Enter direct phone numbers (not switchboard) to location for verification of emergency.
9. Billing Address: (If different) Enter the street address of where the alarm monitoring invoice is to be sent.
10. City, State, Zip Code: (If different) of billing address.
11. Security Alerts: If notices of important policy changes or security matters can not be sent to the billing address, please enter
the e-mail address of where to send these alerts. (Site/branch manager's address or Security Officer's mailing address)
12. Alarm Panel Manufacturer: Select or type in the brand of alarm panel being installed.
(Ademco, Bosch, DMP, Pacom, or Other)
13. Type of Installation: Select or type in the category of alarm installation for monitoring purposes. (Financial, Commercial,
Retail, Residential, Disaster Backup, Government, Other) If Financial is chosen, please indicate if this is a branch or ATM.
Select Branch, if the alarm panel connects to both a branch and an ATM.
14. Type of Primary Communications: Select the type of communication system by which the alarm panel will communicate
(Phone line, network, or cellular). If phone or cellular, please provide the phone number, if known. If network, please select
secure network or internet. If internet connection is selected only one site can be monitored per outside intemet IP address. If
secure network connection is selected and this is not the first site being competed by the EMC then the network connections
have already been completed. Network connections may take longer than 48 hours to prepare for monitoring. To receive
documented instructions for network connections, please e-mail emcctr(adiebold.com with the subject line as "Attn:
Diebold EMC Technical Support Engineer/ Network Alarm ". Please supply your IT contact name and phone number.
15. Type of Backup Communications: Select the source of backup to your primary communication system in the event the
primary is lost, due to vandalism, acts of God, temporary outages, etc. (phone or cellular). Please provide phone number, if
known.
16. Video Monitoring: Select yes or no if this option has been chosen for EMC to monitor event driven video at this location.
To receive documented instructions for video connections, please e-mail emcctrAdiebold.com with the subject line as
"Attn: Diebold EMC Technical Support Engineer/ Video Monitoring ".
17. Events and Codes: The event types are listed in the table on the next page of this reference sheet. Beside each event is a list
of notification options with corresponding codes. Choose and enter one notification code or type in notification instructions,
if other is an option.
Page 4 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
Site Information Form — Reference Sheet
Important: EMC mandates two call verification on all burglary zones (calling site and l' after hours contact before calling police
lowers false alarm incidences) A multitude of local jurisdictions have passed alarm ordinances prohibiting central stations from calling
the police before carrying out two call verification.
Event Choose one option for each event monitored and enter code on form.
Fire (National Fire Alarm Code or National • Fire Dept, Site, Call List • FSC
Electric Code standards must be met by • Fire Dept, Call List • FC
maintenance provider and equipment) • Fire Dept, Guard • FG
• Police, Site, Call List • PSC
Duress (Activated under duress without • Site, Police, Call List • SPC
arousing suspicion) • Police, Call List • PC
• Guard/Security Only • GO
• Other • Type in
• Police, Site, Call List • PSC
Holdup (Activated during a holdup or other • Site, Police, Call List • SPC
dangerous situation) • Police, Call List • PC
• Guard/Security Only • GO
• Other • Type in
• Site, 1 after -hours contact, Police, Call List • SC1OP
Burglary (Activated by forced entry) • Site, Call List, Police • SCOP
• Site, Call List • SC
• • Guard/Security Only • GO
• Call List Only • CO
• Site Only • SO
Supervisory (Equipment monitored 24 • Site, Call List • SC
hours that are never disarmed (i.e.; phones, • Call List Only • CO
batteries, etc.) • Guard/Security Only • GO
• Other
• Type in
• Site Only • SO
Trouble (Problems with alarm components) • Site, Call List • SC
• Call List Only • CO
• Guard/Security Only • GO
• Other • Type in
• Site Only • SO
Panel Test Not Received (Alarm system is • Site, Call List • SC
not sending a test signal) • Call List Only • CO
• Guard/Security Only • GO
• Other • Type in
Access Door Propped (Someone has • Site Only • SO
blocked a door open, during disarmed • Site, Call List • SC
alarm) • Call List Only • CO
• Guard/Security Only • GO
• Other • Type in
• Offense is observed: Voice Down, Police, Site, Call • VDPSC
Video (Video is event driven and viewed List • VDPC
when alarm is tripped) • Voice Down, Police, Call List • PSC
• Police, Site, Call List • SPC
• Site, Police, Call List • PC
• Police, Call List • GO
• Guard/Security Only • Type in
• Other
Two Way Audio Script (Intercom system
allows central station operator to This is Diebold Security, please... • Type in
communicate with occupants when alarm is
tripped)
Other (EMC approval only) • Type in
Page 5 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
-,y
Site Information Form — Reference Sheet
18. Local Agencies: Enter the name and local phone number, including area code of local authority. Please DO NOT enter 911
for any phone number. Many local jurisdictions require businesses to obtain an alarm permit for police dispatching purposes.
Enter the police alarm permit number, type, and expiration date for this site, if required by your local jurisdiction. Diebold
can provide this service for a fee.
19. Authorized Individuals: First, enter the contact information for the individual responsible for the security issues of all
business locations. Next enter contact names in the order to be called for this location, their authority level, whether they are
an after -hours contact, their job title, phone numbers, and e-mail address (if available). If authority level is not chosen, default
is level 1. Cell phone numbers are recommended for after -hour contacts to ensure quick response on security matters.
20. Normal Hours of Operation: Hours site is normally open for business. EMC does not call after hour contacts during
normal business hours, unless otherwise instructed.
21. Holidays Closed: Check "Yes ", if closed for all or most federal holidays and enter any exception dates that the site remains
open or any additional dates the site is closed. Check "No ", if site does not close for any or most federal holidays and enter
any exceptions that the site remains closed or any additional dates the site is closed that are not federal holidays. Select or
type open and close hours of other dates.
22. Supervised Open/Close: This is a chargeable option for EMC to notify a contact when the site does not open or close
according to schedule. Enter number of minutes the site may open early or open late in 15 minute increments. Enter an NO
ALARM for opening minutes, if only closes are to be supervised. Enter number of minutes the site may close early or close
late in 15 minute increments. Select a response plan for the EMC, if an open/close occurs outside set parameters.
23. Revisor Online: This online tool is highly recommended to aid security officers manage their locations and individual site
managers to decrease time spent handling monthly device testing, change requests, and research. Revisor Online requires an
assigned username and pass code to access our secure internet website. If you currently have access, enter yes. If you do not
have access, enter no and visit our website to request access. http : / /securitymonitoring.diebold.com
24. Authorized Signature: Only an authorized level 4 that has been named on the Diebold EMC commercial master agreement
can sign and submit this document by fax or mail.
Diebold sales representatives are responsible for sending EMC the site pricing information and scheduling service to bring
the site live with the Event Monitoring Center.
Contact Information
1- 800 -548 -4478 (Option # 5)
Or e-mail Care Team: emcctr(&,diebold.com
Page 6 of 6 Site Information Form Diebold, Inc. Rev. 4 (9/28/07)
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