City of Temple Terrace Customer Service

2. 
3. Temple Terrace Fire Department Residential Knox Box Request Form
5. Program Information
   This service provides a secured lock box which attaches to the front door of your home. A spare key to your home is locked inside allowing the Temple Terrace Fire Department rapid access to your home during a fire or medical emergency. This reduces our response time in getting to you during medical emergencies where you may not be able to open/unlock the door. This also prevents unnecessary damage to the door or windows of your home. Please have a spare key ready before submitting this form. It is also recommended to have a medical information sheet listing your Name, Date of Birth, medical history, medications, allergies, and emergency contacts.
7. Knox Box applicant / location installation information.
9. First Name*
10. Last Name*
12. Street Number*
13. Street Name*
14. Street Type*
15. Apt #
17. City*
18. State
19. Zip*
21. Cellular Telephone*
22. Home Telephone
24. Do you own your home?*

    1. Yes
    2. No
25. Do you have an alarm?*

    1. Yes
    2. No
26. Do you enter your home from the front door?*

    1. Yes
    2. No
28. Special instructions / comments:
30. Emergency contact information.
32. First Name*
33. Last Name*
35. Cellular Telephone*
36. Home Telephone
38. Relationship to applicant:*
40. Agreement Acknowledgement *

    1. Agree

    Submittal of this form hereby authorizes the City of Temple Terrace Fire Department to install a residential Knox Box at my residence. I understand that this Knox Box is property of the Temple Terrace Fire Department, is on loan to me, and will be returned upon my vacating the premises or if I no longer need the use of this service.
Leave This Blank:


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