2. Your Name*
4. Your Address*
6. Day you will be returning.*
   Day you will be returning.
7. Day you will be leaving.*
   Day you will be leaving.
9. Your Phone Number*
10. Your Email*
12. Who, if anyone, will have access to your house while you're away?*
14. Contact person while you are away.*
16. Phone number for contact person while you are away.*
18. Did you have the papers and mail halted?

    1. Yes
    2. No
19. Is there a radio or light on a timer at the home?*

    1. Yes
    2. No
21. Will there be a vehicle parked at the property?

    1. Yes
    2. No
23. Additional Comments
25. Please read information below before submitting.
27. THE UNDERESIGNED DOES HEREBY GRANT AND REQUEST THE CITY AND ITS POLICE DEPARTMENT TO VISUALLY CHECK UPON THE PROPERTY LISTED ABOVE. THE UNDERSIGNED DOES HEREBY AGREE TO HOLD HARMLESS THE CITY, ITS EMPLOYEES AND AGENTS FOR ANY AND ALL CLAIMS FOR PERSONAL INJURY, LOSS OR DAMAGE TO PROPERTY THAT MAY BE SUFFERED BY THE UNDERSIGNED THROUGH ANY ACTION OR LACK THEREOF BY A REPRESENTATIVE TO THE CITY. FURTHER, THE UNDERSIGNED UNDERSTANDS AND AGREES THAT THIS IS A VOLUNTARY, FREE SERVICE, DOES NOT CREATE A SPECIAL DUTY UPON THE CITY, WILL BE PROVIDED ONLY AS TIME IS AVAILABLE, AND NO GUARANTEE IS MADE NOR ASSURANCE GIVEN AGAINST LOSS, THEFT OR DAMAGE TO PREMISES.
29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Electronic Signature
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field