911-EMERGENCY CELL PHONE PROGRAM

_________________________________________________________
RECIPIENT’S FULL NAME                                                      DATE

_________________________________________________________
STREET ADDRESS                                                                   APT: #

_________________________________________________________
CITY                                               STATE                                      ZIP

_________________________________________________________
                                       HOME PHONE #:                                                                                                                       

_________________________________________________________
CELL TYPE PHONE                                        EMPLOYEE INITIALS

            I do hereby acknowledge receipt of the above named cell phone from Grant Township. I understand that
            there is no service carrier providing regular service and that I will be able to use the phone for emergency
            services only. I do hereby accept full responsibility for any liability that may arise as the result of an
            equipment malfunction or for any reason that the phone may fail to operate normally. I further acknowledge
            that the cell phone was tested in my presence and was found to be working properly.

_________________________________________________________
RECIPIENT SIGNATURE                                                           DATE