Complete the following information and the police department will drive by your
property while you are on vacation.

Contact Information

Name:*

Address:*

City:

State:

Zip:

Phone Number:*

Email Address:

Vacation Information

Date Leaving:*

Date Returning:*

Do you have any lights on?*

Yes

No

Location of Lights:

Any Vehicles in Driveway?*

Yes

No

Vehicle Descriptions:

Emergency Contact Information

Name:*

Address:*

Phone Number:*

Does Emergency
Contact Have Key?*

Miscellaneous Information