Section 1 General Information

*DATE:   Day   Month   Year  *EMAIL:
 

*NAME:First   Last
 

*ADDRESS:Street   City    Zip

* PHONE:   *Mobile

*REASON FOR REQUEST:   i.e. Vacation etc.

*DEPARTURE DATE:   Day  Month   Year  *RETURN DATE:Day   Month  Year

                                                                                                                     Not to exceed 30 days 

*PASSWORD:

Section 2 Destination Information

*DESTINATION ADDRESS:Street   City 

DESTINATION PHONE:  If different from Mobile Phone

Section 3 Property Security & Hazard Information

SECURITY SYSTEM: YES: NO:

AUTOMATIC LIGHT: YES: NO:IF YES, LOCATION:

ANY HAZARDS AT RESIDENCE (I.E. GUNS, ANIMALS, ETC.): YES:NO:

IF YES, LOCATION & DETAILS:

WILL ANYONE BE WORKING ABOUT OR HAVE ACCESS TO PREMISES DURING YOUR ABSENCE? YES:NO:

IF YES, NAME:

Section 4 Emergency Contact Information

HAVE KEYS BEEN LEFT WITH ANYONE? YES:NO:

IF YES, NAME:

ADDRESS:Street   City Zip

PHONE: Home Mobile

If the person you left the keys with is different than your Emergency Contact Person please provide that information below:

NAME:

ADDRESS:Street City Zip

PHONE: Home Mobile

COMMENTS:

I REQUEST A SECURITY CHECK BE MADE OF MY PREMISES. I WILL ALSO NOTIFY YOU IF MY RETURN DATES CHANGES.*

This security check service in no way guarantees that your property will be safe from vandalism or burglary, but merely provides the Lower Swatara Twp. Police Department with information of your whereabouts and other pertinent facts if a crime should occur. This is designed to be a temporary service and will automatically be discontinued on your return date or at the end of 30 days, which ever comes first. Not to exceed 30 days.