Form Center

2. First Name*
3. Last Name*
5. Business Name
7. Street Address*
9. City*
10. State*
11. Zip*
13. E-mail Address*
14. Phone Number*
16. Camera Information
18. Number of Cameras*
20. Camera View(s)*

    1. Front Yard
    2. Back Yard
    3. Driveway
    4. Alley
    5. Front Door
    6. Doorbell
    7. North Side of Property
    8. East Side of Property

    1. South Side of Property
    2. West Side of Property
    3. Patio
    4. Parking Lot
    5. Lobby
    6. Hallway
    7. Room/Office
    8. Other
22. Acknowledgement
    If necessary, the Urbandale 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 Urbandale Police Department and collected from the registrant by the Urbandale Police Department. Your voluntary participation in this program shall not be construed as an obligation to release any surveillance video to the Urbandale Police Department upon request. Any footage containing or related to criminal activity collected by the Urbandale Police Department may be used as evidence during any stage of a criminal proceeding. Under no circumstances shall registrants construe that they are acting as an agent and/or employee of the City of Urbandale and/or the Urbandale Police Department through the program. Under no circumstances shall the Urbandale Police Department utilize any information obtained to view footage/feeds directly from cameras owned by registrants.
24. Please check the box below after reading the acknowledgement.*

    1. I have read and understand the acknowledgement.
26. Electronic Signature*
27. Date*
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field