SecurTek Referral Form

Sales Information

Customer Information

Customer Address
Customer Address
Postal Code


Consent to Share Information
Customer has provided their verbal consent to collect their personal information and share it with SecurTek for the purpose of discussing a home monitoring solution in further detail.
Consent to be Contacted
Customer gives consent for SecurTek to share the personal information provided with a SecurTek Dealer, who requires it for an in-home consultation and fulfillment of a home monitoring solution.

Customer Expectations:

You can add any additional comments/questions/etc. the Customer may have in the Additional Information field.

You can also let the Customer know they can expect to be contacted by Brigadier Security Systems within the next business day.