Business Emergency Contact Information Form

The Business Emergency Contact Information Form will be used to notify the business owner, or the designated contacts, in the event the business property is involved in an emergency situation. This information will only be shared with first responders in the towns of Christiansburg and Blacksburg, Montgomery County, and Virginia Tech.

Business Information
Complete this form if you own or operate a business that is vacant after working hours, are concerned about security on the premises, or have people that you would like the police to contact if a problem were discovered there after business hours.
Business Name*
Business Address*
Street Address Address Line 2 City State ZIP Code
Business Phone Number*
Business or Primary Contact Email Address*
Date
MM slash DD slash YYYY
Contacts
Please list, in order of priority, up to three people that can be contacted in case of an emergency at this location. These should be people that can be contacted during nights, weekends, holidays, early mornings, etc.
Primary Contact Name*
First Last
Primary Contact Number*
Name of Contact # 2
First Last
Contact # 2 Phone
Name of Contact # 3
First Last
Contact # 3 Phone
Name of Contact # 4
First Last
Contact # 4 Phone
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Business Emergency Contact Information Form

Business Information

Contacts