REQUEST FOR SECURITY HOUSE CHECK

Date:____/____/____

Name:____________________ Address to be checked________________Rockford OH 45882

Phone Number: 419-___-_____

Departure date: ____/____/____ Return Date:____/____/____

Destination: ___________________________________________

Security System: Y N _________________________________

Automatic Lights: Y N_________________________________

Have keys been left with anyone? Yes____ No____

If above is yes, who? Name______________________________

Address______________________________

Will anyone be working about or have access to premises during your absence?? If so describe below:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In case of emergency do you wish to be notified by collect call? Yes___ No___ If yes list number: ( )_____-_______

I REQUEST A SECURITY CHECK BE MADE OF MY PREMISES AND AGREE TO NOTIFY YOU OF MY RETURN.

NOTE TO RESIDENT: This security check service in no way guarantees that your property will be safe from vandalism or burglary, but merely provides the department with information of your whereabouts and the pertinent facts if a crime should occur.

Signed:____________________________________ Date:____/____/ ____

Have a safe journey and please call upon your return.

Officers Security Check Report: (Departmental use only)

Date	Time	Unit	Secured	Date	Time	Unit	Secured
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N
			Y or N				Y or N