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2. First Name*
3. Last Name *
4. Phone Number*
6. Email *
7. Alternate Phone Number
9. Address*
11. City*
12. State*
13. Zip Code*
15. Acknowledgement

    If necessary, the Ankeny Police Department will contact you directly, using the information provided by you at the time of registration, to request the video surveillance footage pertaining to the case. Any and all video surveillance footage shall remain the property of the registrant until it is requested by the Ankeny Police Department and collected from the registrant by the Ankeny Police Department. Your voluntary participation in this program shall not be construed as an obligation to release any surveillance video to the Ankeny Police Department upon request. Any footage containing or related to criminal activity collected by the Ankeny 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 Ankeny and / or the Ankeny Police Department through the program. Under no circumstances shall the Ankeny Police Department utilize any information obtained to view footage/feeds directly from cameras owned by registrants.

17. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature*
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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