S.T.O.P.P.E.D. Program Registration

Name:_______________________________________

Address:________________________________________

City:___________________

State:___________

Zipe Code:__________

Telephone:______________________

Email Address:_______________________________________________________

Number of vehicles to enroll:______________

Send notification to (if different from above):

Name:______________________________________________________________

Address:___________________________ City:_____________________________

State:_________ Zip Code:_______________ Telephone:_____________________

Email Addess:________________________________________________________

I wish to participate in the Chautauqua County Sheriff's Office S.T.O.P.P.E.D. Program and fully understand that I may receive notification when an enrolled vehicle, when operated by a driver under the age of twenty-one, is stopped by police.

Signature:____________________________________________________________

Official Use Only

Please print this form, fill it out and mail to:

Chautauqua County Sheriff's Office
S.T.O.P.P.E.D. Program
15 E. Chautauqua Street
P.O. Box 128
Mayville, New York 14757-0128