Form

FreedomCAM Ltd - New Connection Request

This form should only be used when a new FreedomCAM connection is required. If you cannot complete this form, or require assistance please contact 08456 430 832. The information entered into this form is transmitted over a secure connection and within the EU.

Basic Information
Date of Submission *

- Month - Day Year
at
: Hour Minutes
Your Name *

First Name Last Name
Company Name *
Your E-Mail Address *

Site Information
Site Name *
Site Telephone No *

- Area Code Phone Number

Site Address *

Street Address
Street Address Line 2
City	Region
Postal Code	Country

Police Region *

Site Opening/Closing Times
Site Opens (Mon) *

: Hour Minutes
Site Closes (Mon) *

: Hour Minutes
Site Opens (Tue) *

: Hour Minutes
Site Closes (Tue) *

: Hour Minutes
Site Opens (Wed) *

: Hour Minutes
Site Closes (Wed) *

: Hour Minutes
Site Opens (Thu) *

: Hour Minutes
Site Closes (Thu) *

: Hour Minutes
Site Opens (Fri) *

: Hour Minutes
Site Closes (Fri) *

: Hour Minutes
Site Opens (Sat) *

: Hour Minutes
Site Closes (Sat) *

: Hour Minutes
Site Opens (Sun) *

: Hour Minutes
Site Closes (Sun) *

: Hour Minutes
Site Opens (Bank Holidays) *

: Hour Minutes
Site Closes (Bank Holidays) *

: Hour Minutes

Key-Holder Information
Key-Holder 1 Name *

First Name Last Name
Key-Holder 1 Email *
Key-Holder 1 Tel No *

- Area Code Phone Number
Key-Holder 1 Confirmation Word
Key-Holder 2 Name *

First Name Last Name
Key-Holder 2 Email *
Key-Holder 2 Tel No *

- Area Code Phone Number
Key-Holder 2 Confirmation Word
Key-Holder 3 Name

First Name Last Name
Key-Holder 3 Email
Key-Holder 3 Tel No

- Area Code Phone Number
Key-Holder 3 Confirmation Word

Declaration

By ticking the below box and submitting the below form, you confirm that the information contained within this form is correct (so far as you are aware). We cannot accept responsibility for information which has been submitted incorrectly, which results in any Key-Holder/Police/other Authority being either prevented or delayed.
Notes

Use this area to add any additional information which you think is necessary. 0/200
Signature *
Enter the message as it's shown *
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