Request For Security Check

(This form may be printed out and brought to the Police Station.) 

Date Leaving: ___________________ Date Returning: ___________________

Name: _____________________________ Phone: _____________________

Address: ________________________________

Party taking care of residence: _______________________ Phone: _____________

Address ________________________________ They have a key Yes__ No __

Will anyone be working around residence during your absence Yes __  No __

Names: _____________________________________________________

Are any lights on timer? What location/time? ________________________________

Are any lights on constantly? Location ___________________________________

Will your vehicle be left out? Where? ______________________________________

What vehicle? ______________________________________________________

Will the mail/newspaper be picked up? Yes __ No __

In an emergency do you wish to be called? Yes __ No __ # ____________________

Name _____________________________________ Address ___________________

Today's Date _________________