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2. **Property Owners, Renters, or Leasers of property may request a Security Check for property. Patrols will not last for over 10 days unless approved by Chief of Police**
4. PHYSICAL ADDRESS (TO BE CHECKED) *
6. STRUCTURE TO BE CHECKED*

   1. BUSINESS
   2. RESIDENCE
   3. OTHER
8. CITIZEN REQUESTING CLOSE PATROL*
10. MAILING ADDRESS (CITY, STATE, ZIP TO SEND REPORT BY MAIL ONCE COMPLETED)*
12. DATE TO BEGIN*
14. DATE TO END*
16. REASON FOR REQUEST*
18. WILL ANYONE HAVE ACCESS TO PREMISES*

    1. YES
    2. NO
20. IF YES PROVIDE NAME AND PHONE NUMBER *
22. WILL ANY LIGHTS BE LEFT ON PREMISES*

    1. YES
    2. NO
24. IF YES WHERE
26. WILL ANY VEHICLES BE PARKED ON PREMISES*

    1. YES
    2. NO
28. IF YES VEHICLE #1 LICENSE PLATE, COLOR, AND YEAR
30. IF YES VEHICLE # 2 LICENSE PLATE, COLOR AND YEAR
32. INCASE OF EMERGENCY DO YOU WISH TO BE CONTACTACTED*

    1. YES
    2. NO
34. IF YES TELEPHONE NUMBER
36. LIST ANY HAZARDS ON PROPERTY (LOCKED GATES, POOLS, DOGS, ETC)*
38. ADDITIONAL INFORMATION
40. 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.
42. Electronic Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field