CMRS PSAP CERTIFICATION APPLICATION
PSAP:_____________________________________________________________________________________________________________
Mailing Address: ____________________________________________________ City: __________________________________________
Zip: _____________________ County: ___________________________________________ Phone # ________________________________
e-mail address: _______________________________________________________________ Fax #: _________________________________
Location (if other than Mailing Address):________________________________________________________________________________
Contact Name:
________________________________________ Title: __________________________________________e-mail address
: _______________________________________ Phone #: __________________ Fax #: _________________Is this a: (circle one)
Local PSAP Regional PSAP If this is a Regional PSAP - list below jurisdictions served:PSAP currently providing: (circle one)
Enhanced 9-1-1 Basic 9-1-1 _____________________________________Under what authority does the PSAP operate: (circle one)
____________________________________Agency Local/Regional Board Fiscal Court City Gov't _____________________________________
Authority Name
: ___________________________________________________________________________Authority Head's Name: ___________________________________________ Phone #: __________________ Fax #: __________________
1. Telephone Company providing 9-1-1 service: ___________________________________________________________________________
Company Contact: ____________________________________________ Phone #: ____________________ Fax #: ___________________
2. Telephone Company providing 9-1-1 service: ___________________________________________________________________________
Company Contact: ____________________________________________ Phone #: ____________________ Fax #: ___________________
Remarks:___________________________________________________________________________________________
__________________________________________________________________________________________________
I certify to the best of my knowledge that the information contained in this application and attachments is accurate and correct.
Name (printed)
____________________________________________ Title: ______________________________________
Signature
_________________________________________________________ Date: ______________________________Attach additional sheets as necessary This form may be reproduced Updated December 02, 1999