RESIDENTIAL SECURITY CHECK REPORT

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NAME: ______________________________________ ADDRESS: _____________________________________

DATE LEAVING: __________________________ DATE RETURNING: _________________

TYPE PREMISES: ___ RESIDENCE ___ BUSINESS ___ OTHER (SPECIFY)______________________

ALARM SYSTEM? ___ YES ___ NO TYPE ALARM: ___ SILENT ___”NOISE”

LIGHTS: ___ ON CONSTANTLY ___ TIMER/AUTOMATIC ON/OFF

VEHICLE(S) ON PREMISES? ___ NO ___ YES MAKE: ____________ COLOR: _________ LP#: _________

DOG(S) ON PREMISES? ___ NO ___ YES, IF YES, WHAT IS THE ANIMAL’S RANGE?

_____ BACK YARD ONLY ___ FRONT YARD ONLY ___ ENTIRE YARD

IS YOUR ADDRESS PLAINLY VISIBLE? ___ NO ___ YES

IF YES: ___ ON HOUSE ___ ON MAILBOX ___ OTHER(SPECIFY):________________________________

IF NO: DESCRIBE HOUSE: ____________________________________________________________________

KEYS LEFT WITH ANYONE? ___ NO ___ YES NAME: _________________ PHONE #:_____-_____-_____

IN CASE OF AN EMERGENCY, DO YOU WISH TO BE NOTIFIED BY A COLLECT CALL?

___ YES ___ NO IF YES, PHONE # WHERE YOU CAN BE REACHED: _____-_____-_____

DATE TIME PREMISES SECURE (IF NOT, STATE ACTION TAKEN) OFFICER

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REQUEST TAKEN BY: ________________________________ DATE: ___________________ TIME: _______

I AM REQUESTING EXTRA PATROL FOR THE ABOVE LISTED ADDRESS AND I DO NOT HOLD THE LIBERTY POLICE DEPT. LIABLE FOR ANY DAMAGES FOUND AND/OR PROPERTY MISSING FROM THE ADDRESS LISTED ABOVE, IN THE EVENT OF MY ABSENCE.

SIGNATURE OF PERSON REQUESTING EXTRA PATROL: _____________________________________

DATE: ___________________________________ TIME: ____________________ A.M./P.M.