MIDLAND COUNTY CENTRAL DISPATCH AUTHORITY

ENHANCED 9-1-1

AUTOMATIC DETAIL INFORMATION FORM

Your telephone number and special conditions or instruction you provide to the Midland County Central Dispatch Authority will automatically display on the 9-1-1 system when called from a land line phone.

Please fill in the requested information below. The information you provide is critical in assisting local authorities responding 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.

Current Information:
Home Telephone No:
Cell:
Work:
Last Name:
First:
Date of Birth:
Street Address:
APT#:
City:
Zip Code:
Nearest Cross Street or Additional Directions:
Email address:
Check Yes if you would like to be updated annually via e-mail.	Yes No
THIS ADDRESS IS A(check all that apply):	House Mobile Home Apartment Duplex Condo Farm Business Owner Occupied Rented
THEE FOLLOWING HAZARDOUS MATERIALS EXIST AT THIS ADDRESS:	Gasoline Diesel LPG Other Chemicals Ammunition Explosives Pesticides Poisons Radio Active Material Paints Excessive Quantities of any of above
SPECIAL NEEDS PERSON AT THIS ADDRESS:
Last Name:
First Name:
Date of Birth:
Additional Information:	Hearing Impaired Use of TTY/TDD (telephone for deaf) Sight Impaired Mentally Handicapped Alzheimer/Memory Impaired Bedridden On Oxygen Supply Physically Handicapped Under Medical Care for Heart Problems
Other:
There is a Key located at:
Emergency Contact Person(s)
Alarm Company:
Neighborhood Watch Participant:	Yes No
If Yes, what is your captain's name?
Special Animals/Livestock
Incidents may arise that require 911 to contact residents regarding missing or located animals:
Please indicate animals at this address and the number of each:
Dog	Yes No
Breed:
Color:
License or reg#:
Animals or Livestock	Cat Horse Cows Pigs Buffalo Emus Llamas Turkey Chickens
Other:
Service Animal:	Yes No
Type:	Seizure Guide Hearing
License or Reg#:
If and of the above is indicated, please include a phone number where you may be reached in case of an animal emergency:
Work:
Home:
Cell/Pager

Click here to put a form like this on your site.