Vacant House Check Request Form

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Name: *

(First & Last Name)

Full address: *

Home Phone:

Cell Phone: *

Date Leaving:

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Date returning:

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Emergency Contact

(Emergency contact is who you want us to contact if there is an emergency while you are away.)

Primary Emergency Contact's name:

Primary Emergency Contact's address:

Primary Emergency Contact's phone #:

Secondary Emergency Contact's name:

Secondary Emergency Contact's address:

Secondary Emergency Contact's phone #:

Will anyone be stopping by to pick up your mail, let pets out, water plants, etc?

Yes

If so, please provide their name(s) and description of their cars they may be parking in your driveway:

Are you leaving any vehicles in the driveway or garage?

Yes

Vehicle description (be specific) & license plate #:

Will there be any lights on inside or outside of the residence and are they on a timer? *

Is your house alarmed? *

Yes

If alarmed, company name and phone #:

What would you like the Officers to do? *

Any other information you would like us to know about your property? (Animals, service people/companies, etc.)

Electronic signature: *

By signing this form you are authorizing the members of the Waupun Police Department to be present on your property and enter your residence should an emergency be discovered.

Vacant House Check Request Form

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