Secure Home Order Form

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Secure Home Order Form
To place an order, fill out the form below. If your browser has JavaScript capability, the total will be automatically calculated as you fill out the form; otherwise, it will be calculated when you click on the "Verify Order" button. Either way, you will have an opportunity to review the order before final entry.

Qty	Description	Price	Line Total
	Basic Package	$1,595
	Door Sensor	95
	Motion Sensor	105
	Smoke Detector	159
	Keychain Remote	50
	External Strobe/Siren (Weatherproof)	79
	Emergency Pendant	80
	Wireless Keypad	80
	Glass Break Sensor	159
Total
Internet Grand Opening Special -40%
Shipping			$20
Order Total

Name

Address

City
State Zip

Phone:

Card Type: Visa MasterCard

Card Number:

Cardholder Name:

Expiration Date:

Payment Method:
Credit Card
C.O.D.
Check

Order Method:
Internet
Fax
Postal Mail
Phone

Select a payment method above, and a method of submitting your order. After filling out this form, click on the "Verify Order" button, and you will receive further instructions.

We are not yet able to accept credit cards over the Internet, so if you wish to pay by credit card, please use Fax, Postal Mail or Phone.

You need to specify a passcode for the monitoring company operators. In the event of an alarm, the operator will ask for this passcode, via the alarm system. If the person present is unable to provide it, the operator will call the police. The passcode is simply a word, up to six characters. It can be changed at any time by calling the monitoring company.
Passcode:

The system can only be disarmed with the remote control, or with a disarm code. Please specify a three- or four-digit master disarm code:

And up to two secondary disarm codes:

Again, you can change these codes at any time.

You can specify up to 5 persons to be called in the event of an alarm:

Name Phone 1 Phone 2

In order to send you the correct door sensors, we need to know what kinds of doors you have. If the surface of the door is even with surface of the wall, specify "flush"; if it is inset -- that is, there's a frame or moulding around it -- specify "inset".
Number of flush doors:
Number of inset doors:

Questions or comments? info.securehome@holotech.net

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