Time Leaving: Time Returning: Type: ResidentialBusiness
Name: Street Address:
Main Contact Number: Secondary Contact Number:
Alarm :NoYes Alarm Company:
Alarm/Key Holder/Contact Person: List all names and contact numbers
Light(s) left on or on timers (list areas):
Vehicles left in driveway, around house, or allowed on property during vacancy:
Pets on Property: NoYes Dangerous: NoYes
Type of Pets:
Persons allowed around residence or looking after property: (List all names and contact numbers)
Statement of Limited Liability: It is hereby understood that in consideration for the Newton Police Department keeping check on my/our property that I/we hereby release the Newton Police Department from any liability from loss or damage to my property. By submitting this form you understand/agree to the limited liability clause and agree to receive a preliminary phone call from the Newton Police Department to check the validity of this request.
_______________________Office Use Only______________________________
OCA#_________________________
Special Observations:______________________________________________________
________________________________________________________________
Date/Time:_____________________________________
Supervisor's Initials:__________________________________