VACATION FORM

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Date leaving: ______________________     Date returning: ______________________

 

Address: ______________________________________________________________

 

Owner: __________________________________

 

Owner can be reached?   No    Yes – Phone _______________

 

Emergency contact:

Name _________________________ Phone _______________

 

Keyholder:

Name _________________________ Phone _______________

 

Persons expected/authorized to be on premises:

Name: _________________________ Phone: _______________

Name: _________________________ Phone: _______________

 

Grass mowed or driveway shoveled?   No    Yes  

 

Existing damage to windows, doors, or fence?   No    Yes   –   Description: ___________________

 

Vehicles in driveway?   No   Yes  –  Description/plate: __________________________________

 

Lights left on or on a timer?   No    Yes  –  Location, times: ______________________________

 

Pets left on premises?   No   Yes  –  Description, location: _______________________________

 

Date/Time     Officer         Observations

__________     __________    _______________________________________________________________ 

__________     __________    _______________________________________________________________

__________     __________    _______________________________________________________________ 

__________     __________    _______________________________________________________________

__________     __________    _______________________________________________________________

© 2020 Belleville Police | Designed by Keith Cleasby

Belleville Police Department | 61 Frederick Street |  Belleville, WI 53508 | 608-424-3129