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2. Contact Information
4. First Name*
5. Last Name*
7. Business Name (if applicable)
9. Street address (location of cameras)
11. Phone number*
12. Alternative phone number
13. Email address
15. Preferred method of contact*
    -- Select One --PhoneEmail
16. Best time to contact you
    -- Select One --MorningAfternoonEveningAnytime
18. Additional contact information
20. Camera Information
22. Number of cameras*
23. Do the cameras have audio? If so, which ones?*
25. Video format*
26. How long is the video stored?*
27. How is the video accessed?*
29. Camera views*

    Select all that apply

    1. Front yard
    2. Back yard
    3. Driveway
    4. Alley
    5. Front door
    6. Back door
    7. Street
    8. Patio
    9. North side of property

    1. South side of property
    2. West side of property
    3. East side of property
    4. Lobby
    5. Hallway
    6. Rooms/office
    7. Parking lot
    8. Other
31. Additional comments
33. Acknowledgment
35. If necessary, the Pella Police Department will contact you directly, using the information provided by you at the time of registration, to request the appropriate video surveillance footage. Any and all video surveillance footage shall remain the property of the registrant until it is requested by the Pella Police Department and collected from the registrant by the Pella Police Department. The PCCP does not grant the Pella Police Department the right to directly or remotely access a registered individual’s camera(s), cloud storage, or surveillance footage unless expressly authorized by the registered owner. Your voluntary participation in this program shall not be construed as an obligation to release any surveillance video to the Pella Police Department upon request. Any footage containing or related to criminal activity collected by the Pella Police Department may be used as evidence during any stage of a criminal proceeding. This program is entirely voluntary; registrants can withdraw consent for the inclusion of their camera information in the VSCRP database at any time. Under no circumstances shall registrants construe that they are acting as an agent and/or employee of the City of Pella and/or the Pella Police Department through the program.
37. Signature*
38. Date*
    Date
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42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field