VACATION FORM

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: _______________

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

__________ __________ _______________________________________________________________