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Monitoring Intake Form
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Legal Name
*
First
Last
Supervision Type
*
Probation
Parole
Pretrial
Other
Offense Charge(s)
*
Details of your offense:
*
Are you allowed any contact with minors?
*
YES
NO
UNKNOWN
Their Name/Their Age/Your Relationship to Them/Type(s) of Contact Allowed
Are you permitted to access any social media accounts or other accounts that allow for online, real time, peer to peer communications?
*
YES
NO
UNKNOWN
Website/Username
Are you involved in a significant/sexual relationship?
*
YES
NO
UNKNOWN
Their Name/Contact Name on Device/ Phone Number/Email Address
Are you permitted to use the camera on your device?
*
YES
NO
UNKNOWN
Are you permitted to access Craigslist
*
YES
NO
UNKNOWN
Are you permitted to access YouTube
*
YES
NO
UNKNOWN
Select an option below:
*
New client
Current AJ Monitoring client, no changes to current payment arrangements
Current AJ Monitoring client, would like to make changes to current payment arrangements
For your monthly payment, would you like to keep a card on file to auto deduct or for AJ Monitoring to send you a monthly invoice?
*
Keep card on file
Monthly invoice sent by email
Bank transfer
Other
Billing Zip Code
*
Last 4 digits of your card #
AJ Monitoring will call you for the full card number after your install. Please do not enter your full card number here.
Expiration Date:
*
Monthly Charge Conditional Acknowledgment:
*
By selecting automatic billing, I acknowledge my card will be charged according to pricing for selected services. I acknowledge my card will be charged monthly until services are terminated or I provide written cancellation to AJ Monitoring. **Monthly pricing: $65/month per device, $30/month for each additional computer monitor. Ultrawide monitors will be charged as two monitors. There is a multi device discount of $5 off per device.
Please specify payment arrangements:
For your yearly license renewal, would you like to keep a card on file to auto deduct or for AJ Monitoring to send you an invoice?
*
Keep card on file
Invoice sent by email
Bank transfer
Other
If you are required to be on monitoring one year from now you will be due to renew your yearly license.
Yearly Charge Conditional Acknowledgment:
*
By selecting automatic billing, I acknowledge my card will be charged according to pricing for selected services. I acknowledge my card will be charged yearly until services are terminated or I provide written cancellation to AJ Monitoring. **Yearly pricing: $100/year per device for a license renewal.
Please specify payment arrangements:
Is this device replacing an old monitored device?
*
Yes
No
What are you doing with the old device?
*
Additional Information:
Email
*
*
I understand I am signing this form voluntarily and I certify that all the information contained in this form is true and complete.
Signature
Clear Signature
Date
Comment
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