Police Service of Northern Ireland s1

APPENDIX F – CCTV RESTRICTED Pages 1 of 3

POLICE SERVICE OF NORTHERN IRELAND APPLICATION FOR THE ISSUE OF AN UNIQUE REFERENCE NUMBER FOR A CCTV SYSTEM

Please include Certificate of Compliance and quote Certificate Number: What is the Alarmed Premises Grid Reference?

1. ALARM COMPANY 4. CCTV Name: PLEASE SEE Address: APPENDIX R – REQUIREMENTS FOR COMPANIES INSTALLING AND MONITORING REMOTE CCTV SYSTEMS - www.psni.police.uk/appendix_r_- Post Code: _requirements_for__installing_and_monitoring_ Tel No: remote_cctv_systems_-_january_2012.pdf Fax No: 5. STANDARDS Please √ 2. PROTECTED PREMISES DOES THE SYSTEM COMPLY WITH Name: BS 8418 Trading Name: 6. RVRCs STANDARDS Please √ Premises Type: DOES RVRC MONITORIING Address: DETECTOR ACTIVATED CCTV SYSTEM CONFORM WITH BS 5979 (CAT 11) 7. ADDITIONAL FEATURES PLEASE STATE: CHEMICAL TRACE: Post Code: SMOKE GENERATOR: 3. CORRESPONDENCE ADDRESS OTHER: Name: Address: 8. REMOTE VIDEO RESPONSE CENTRE Name: Address:

Post Code: Correspondence to be sent to: Please √ Correspondence address only, or Post Code: Premises and correspondence address Tel No:

9. KEYHOLDER 1 10. KEYHOLDER 2

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Name: Name: Address: Address:

Post Code: Post Code: Home Phone: Home Phone: Work Phone: Work Phone: Mobile: Mobile: 11. KEYHOLDER 3 12. KEYHOLDER 4 Name: Name: Address: Address:

Post Code: Post Code: Home Phone: Home Phone: Work Phone: Work Phone: Mobile: Mobile:

13. ANY OTHER DETAILS (Including directions to the premises from the main road)

Data Protection Act 1998 Personal data supplied on this form may be held on, and/or verified by reference to information already held on computer.

POLICE SERVICE OF NORTHERN IRELAND HAZARDS AND SITE RISKS - HEALTH & SAFETY ACT

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(MUST BE COMPLETED BY OCCUPIER) Police officers will not normally enter the premises without the keyholder. However, this may be necessary on occasions due to suspicious circumstances. So officers may be pre-warned of site risks you are required to state any site hazards. 14. Hazard details apply to the building(s) and grounds of these Please tick: √ premises.

POND BASEMENT DOGS CONTAGIOUS SAMPLES

SWIMMING POOL FRAGILE ROOF DANGEROUS ANIMALS FLAMMABLE SUBSTANCES

DANGEROUS RIVER FRONTAGE FIREARMS FUEL STORAGE STRUCTURE LOW CEILING GLASS COPING WALLS AMMUNITIONS CHEMICALS BEAMS SLIPPERY RAZOR WIRE EXPLOSIVES RADIO ACTIVE MATERIALS FLOORS DANGEROUS INSPECTION PITS FURNACE ASBESTOS MACHINERY ELECTRICITY SETTLEMENT TANKS GAS CYLINDERS SPRINKLER SYSTEM SUB-STATION ATM INSIDE VATS TOXIC MATERIALS PREMISES STATE OTHER SITE HAZARDS OR IF NO SITE HAZARDS OR RISKS, STATE NONE:

Should site circumstance change you must update our records. 1. I have been given Appendix ‘I’ and Appendix ‘H’ by the Security Company. I have read, understand and agree to abide by the NPCC Guidelines on Police Requirements & response to Security Systems and the PSNI Annexe A, Additional Operation Restrictions for PSNI. This Policy can be downloaded from: http://www.securedbydesign.com/wp- content/uploads/2015/08/Security_Systems_Policy_2015.pdf and www.psni.police.uk/index/crime-prevention/security_systems_policy.htm 2. I am aware that there is a police Alarms Administration fee payable (£43.49 + VAT) on the issue of each PSNI Unique Reference Number. 3. In particular I have noted the keyholder requirements.

Signed (Customer): -

If this form is not completed the Appendix will be returned unprocessed. Signed (by or on behalf of the Alarm Company): - Position in Company: - Date: -

Data Protection Act 1998 Personal data supplied on this form may be held on, and/or verified by reference to information already held on computer.

RESTRICTED