House Check Request Form

Name of Applicant*
First Last
Departure Date*
Date Format: MM slash DD slash YYYY
Return Date*
Date Format: MM slash DD slash YYYY
Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address Same as Street Address?
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Daytime Phone*
Email
Emergency Contact Information
Name of Contact
First Last
Relationship
Phone
Email
Keys Available?
Location of Keys
Alarm Company?
Alarm Company Phone
Security Code
Mail Service Stopped?
Do You Have Newspaper Service?
Newspaper Delivery Stopped?
Others on Property During Homeowner Absence
Will There Be Anyone on the Property?
Name(s)
Enter one name per space. For additional spaces, click the plus sign to the right of the space.
Relationship(s)
Enter one per space. For additional spaces, click the plus sign to the right of the space.
Purpose for Visit(s)
Enter one per space. For additional spaces, click the plus sign to the right of the space.
Vehicle Make(s) and Model(s)
Enter one make and model per space. For additional spaces, click the plus sign to the right of the space. If you do not know the vehicle make/model, type "Unknown".
Other Vehicle(s) on Property
Will There Be Other Vehicle(s) on Property?
Only check "Yes" for vehicles not listed in the "Others on Property" section above.
Vehicle Make(s) and Model(s)
Enter one make and model per space. For additional spaces, click the plus sign to the right of the space.
Animal(s) on Property
Will There Be Any Animals on Property?
Description(s) of Animal
Enter one per space. For additional spaces, click the plus sign to the right of the space.
Location(s) of Animal
Where will the animal(s) be located on the property? Enter one per space. For additional spaces, click the plus sign to the right of the space.
Note: This out-of-town check does not guarantee that a burglary or other crime will not occur at the residence. Is it intended to be a request for the Officer on duty to check the home periodically, based on the availability of the Officer. No guarantee is made as to the frequency, duration or availability of the requested house checks. No further police protection, service or response is guaranteed by the out-of-town house check that is normally provided to the general public. Consequently, it is recommended that homeowners make every effort to safeguard against losses, included securing of high value property, proper locking devised, alarms, etc.
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House Check Request Form

Emergency Contact Information

Others on Property During Homeowner Absence

Other Vehicle(s) on Property

Animal(s) on Property

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