Emergency Contacts Form

Use this form to update the emergency contact information for your business or residence. The information you provide will be kept on file with the Garfield County Emergency Communications Center and will only be shared with emergency responders (Police, Fire, EMS) in the event of an emergency. This form may be used by any business or residence located within Garfield County.


Today's Date (mm/dd/yyyy)	*
Your Email Address	*
Your Name	*
Your Date of Birth (mm/dd/yyyy)	*
Your Phone Number
Address Line 1	*
Address Line 2
City	*
State	*
ZIP Code	*

Please enter the location's information:
Is the information the same as above?		No Yes
Business name
Address
Apartment or Suite
City
Main Phone

Please enter the Emergency Contacts:
Name
Phone #1
Phone #2

Name
Phone #1
Phone #2

Name
Phone #1
Phone #2
Please indicate if there is anything that may pose a hazard to responders at the location:
Security Code	*