Name * Address * City * State * Zip Code * Phone Number * Date Leaving * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Date Returning * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Where can you be reached while away? Cell Phone Number Who can we contact locally in case of emergency? Their Phone Number Do they have a key? Yes No Will there be lights on while you are away? Yes No If so, where? If so, when? Have you stopped all deliveries? * Yes No Will your property be taken care of? * Yes No Is there an alarm system * Yes No Disclaimer * I Agree I acknowledge that the Locust Township Police Department assumes no responsibility or liability for the property identified herein and that I further release and indemnify the Locust Township Police Department, its employees, or agents from any damages or liability for providing this service. Additionally, I understand that the Locust Township Police Department advises that the information collected on this form does not indicate, nor imply, that the Locust Township Police Department will provide any checks or inspections of the property during the duration of the vacancy. The information collected herein will be used solely for making emergency contact with a responsible party should a problem at this property be discovered or reported to the Locust Township Police Department. Submit
