House Check Form

Request the Police Department watch your house while you are away.

Name *

Phone Number *

Address *

Reason For Request *

Premise Will Be Vacant

Other

Type of Premise *

Residence

Business

Other

Protected By Alarm System? *

Yes

No

If Yes, Type of Alarm

Keys Left With Someone

Yes

No

Key Holder Name

Key Holder's Phone Number

Key Holder's Address

Lights On?

Yes

No

Lights Constant?

Yes

No

Mail/Paper Service Stopped?

Yes

No

Others With Permission/Access To Premise

In Case of Emergency, Do You Wish To Be Contacted?

Yes

No

I Wish a Security Check Be Made of my Premise From Date

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Year Year20242025202620272028

To Date

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year20242025202620272028

Leave this field blank