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House request form

* indicates a required answer.

Waupun Police Department Vacant House Check Request Form:

1. *

Name (first and last):

2. *

Full address:

3. *

Home Phone:

4. *

Cell Phone:

5. *

Date Leaving:

6. *

Date returning:

(Emergency contact is who you want us to contact if there is an emergency while you are away.)

7.

Primary Emergency Contact's name:

8.

Primary Emergency Contact's address:

9.

Primary Emergency Contact's phone #:

10.

Secondary Emergency Contact's name:

11.

Secondary Emergency Contact's address:

12.

Secondary Emergency Contact's phone #:

13.

Will anyone be stopping by to pick up your mail, let pets out, water plants, etc?

yes no
14. 

If so, please provide their name(s) and description of their cars they may be parking in your drivway:

15.

Are you leaving any vehicles in the driveway or garage? 

yes no
16. 

Vehicle description (be specific)  & license plate #:

17.*

Will there be any lights on inside or outside of the residence and are they on a timer?


Use your Ctrl & Shift keys to select multiples.
18.

Is your house alarmed?

yes no
19.

If alarmed, company name and phone #:

20.*

What would you like the Officers to do?


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21. 

Any other information you would like us to know about your property?  (Animals, service people/companies, etc.)

By signing this form you are authorizing the members of the Waupun Police Department to be present on your property and enter your residence should an emergency be discovered.

22. *

Electronic signature:

FOR POLICE DEPARTMENT USE ONLY:

23.

Date received:

24.

Date Entered:

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