Free Visa Gift Card Request Form

We want to take this opportunity to thank you for your business. To confirm the continued quality performed by our installers. We ask that you complete this brief questionnaire. Our questionnaire completes the process that the security system has been installed and activated. This confirmation will also begin the process of the mailing of your Visa Gift Card per our promotion.

Download, Fill & Print Form

"$99.00 Customer Installation Charge. 36-month monitoring agreement required starting at $33.99 per month ($1223.64). 24-month monitoring agreement required in California at $33.99 per month ($815.76). Form of payment must be by credit card or electronic charge to your checking or savings account. Offer applies to homeowners only. Local permit fees may be required. Satisfactory credit history required. Certain restrictions may apply. Offer valid for new ADT Authorized Dealer customers only and not on purchases from ADT Security Services, Inc. Other rate plans available. Cannot be combined with any other offer." Licenses: AZ: ROC255474, CA: ACO5325, CO: 1037585, FL: EF20000905, GA: LVU46182, ID: C189433, IL: 127.001386 / 124.001663, IN: 92706 (Indianapolis: 174231), KS: 10969 (Lenexa), KY: 0746019, MI: 3601205667 / 60184G, MN: 3102180-2, MO: 00504375, NE: 10117387, NJ: 34BX00006600, NY: 12000298581, NC: 2889-CSA (Charlotte: 617907), OH: 1804841, OK: 182, PA: 82635484, TX: B14839, UT: 7583233-6501, VA: 11-6402, WA: SAFEHHS89885 / UBI #603-012-274