Monitoring Intake Form – AJ Monitoring

Legal Name *

First

Last

Supervision Type *

Offense Charge(s) *

Details of your offense: *

Are you allowed any contact with minors? *

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? *

Website/Username

Are you involved in a significant/sexual relationship? *

Their Name/Contact Name on Device/ Phone Number/Email Address

Are you permitted to use the camera on your device? *

Are you permitted to access Craigslist *

Are you permitted to access YouTube *

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? *

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: $60/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? *

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? *

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

Date