Alert Sentry Order Portal – Alert Sentry Order Form

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	Product	Price
Traditional Home-Based System
	ASG Standard System w/ Fall Detector - Quarterly Standard System w. Fall - Home Base System - Landline Required Monitoring - $ 89.85 per quarter ($ 29.95/mo.) Activation - FREE Shipping - FREE	89.85
	ASG Standard System w/Fall Detector - Monthly Standard System w. Fall - Home Base System - Landline Required Monitoring - $ 34.95 per month Activation - FREE Shipping - FREE	34.95
	ASG Standard System - Quarterly Standard System - Home Based System - Landline Required Monitoring - $ 59.85 per quarter ($ 19.95/mo.) Activation - FREE Shipping - FREE	59.85
	ASG Standard System - Monthly Standard System - Home Based System - Landline Required Monitoring - $ 24.95 per month Activation - FREE Shipping - FREE	24.95
Traditional Home-Based System - Cellular, no phone line required
	ASG Standard Cell System w/ Fall Detector - Quarterly Home Based System w. Fall Detect - No Landline Required Monitoring - $ 119.85 per quarter ($ 39.95/mo.) Activation - FREE Shipping - FREE	119.85
	ASG Standard Cell System w/ Fall Detector - Monthly Home Based System w. Fall Detect - No Landline Required Monitoring - $ 44.95 per month Activation - FREE Shipping - FREE	44.95
	ASG Standard Cell System - Quarterly Cellular System - Home Based System - No Landline Required Monitoring - $ 89.85 per quarter ($ 29.95/mo.) Activation - FREE Shipping - FREE	89.85
	ASG Standard Cell System - Monthly Cellular System - Home Based System - No Landline Required Monitoring - $ 34.95 per month Activation - FREE Shipping - FREE	34.95
iSAFE
	iSafe - Quarterly Mobile PERS - GPS Monitored Monitoring - $ 89.85 per quarter ($ 29.95/mo.) Activation - $ 25.00 (onetime fee) Shipping - FREE	114.85
	iSafe - Monthly Mobile PERS - GPS Monitored Monitoring - $ 34.95 per month Activation - $ 35.00 (onetime fee) Shipping - FREE	69.95
iSAFE Plus
	iSafe Plus - Quarterly Mobile PERS w. Fall Detection - GPS Monitored Monitoring - $ 119.85 per quarter ($ 39.95/mo.) Activation - $ 25.00 (onetime fee) Shipping - FREE	144.85
	iSafe Plus - Monthly Mobile PERS w. Fall Detection - GPS Monitored Monitoring - $ 44.95 per month Activation - $ 35.00 (onetime fee) Shipping - FREE	79.95
Accessories
	Lockbox - Door Knob Mount Keep your door locked 24 hours a day, while your family, friends and emergency personnel have access to your home. Hangs on the door knob	24.95
	Lockbox - Wall Mount Keep your door locked 24 hours a day, while your family, friends and emergency personnel have access to your home. Hangs on the door knob	24.95

Total

Total Amount *

Subscriber Information (Person Using System)

First Name *

Gender Male Female

Last Name *

Date Of Birth

Address 1 *
Address 2

City *

State *

Zip *

Phone 1 * (xxx-xxx-xxxx)

Check If Cell

Medical Information

Shipping Address, if different than the Subscriber Address.

ShipTo Address

Use subscriber's address

First Name *
Last Name *
Address 1 *
Address 2

City *

State *

Zip *

Phone * (xxx-xxx-xxxx)
Email

Responders

#	Name	Relationship	Phone	Ph. # Type
1	Name	Rel.	Phone (xxx-xxx-xxxx)	H	W	C
2	Name	Rel.	Phone (xxx-xxx-xxxx)	H	W	C
3	Name	Rel.	Phone (xxx-xxx-xxxx)	H	W	C
4	Name	Rel.	Phone (xxx-xxx-xxxx)	H	W	C
5	Name	Rel.	Phone (xxx-xxx-xxxx)	H	W	C

Payment Information (Cardholder or Bank Account Owner)

Use subscriber's information
Use shipping information

First Name *
Last Name *
Address 1 *
Address 2

City *

State *

Zip *

Phone * (xxx-xxx-xxxx)
Email for receipt

Payment Method

Credit Card

Bank Draft

Credit Card - MC, Visa, Discover, Amex

Card Number	Expiration			Security Code
CC# *	mm *	/	yy *	CVV2 *

Bank Draft

Bank Name *

Name on Check *

Routing # * (9 digits)

Account # *

Notes

Enter Notes