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   Franklin County Department of Public Safety
   50 Claiborne Ave. • Rocky Mount, VA 24151
   540-483-3091
5. Do Not Call Release Form (Please Read statement in it's entirety)

   I am aware that the Franklin County Department of Public Safety (Client) has subscribed to an alert system known as CodeRed or SmartNotice for the purpose of communicating time sensitive notifications, including without limitation emergency alerts, employee-related alerts, or other important alerts.

   By completing this form, I choose to be placed on the DO NOT CALL list for service alerts issued by the Client. I understand that I may miss time-sensitive notifications, including those regarding emergencies. By signing this release, I waive all claims against the Client and ECN, their officers, agents and employees in the event that members of my household, my property, or I are adversely affected due to my request to stop receiving alerts.

7. Name*
8. Phone number (s)*
10. Street Address, City, State, Zip*
12. Email Address*
14. BY TYPING or SIGNING YOUR NAME, YOU ARE CERTIFYING THAT YOU HAVE READ AND AGREE WITH THE FOLLOWING STATEMENT IN ITS ENTIRETY.
    I agree that my typed name on this document is the legally binding equivalent to my handwritten signature, and that the information provided is true and accurate.
16. Signature*
17. Today's Date*
    Today's Date
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

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