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2. Request Date*
   Request Date
4. First Name
5. Last Name
7. Address to be checked*
9. City
10. State
11. Zip Code
13. Date span to be checked*
    Date span to be checked Start Date

    —

    Date span to be checked End Date

    Enter the date that you will leave the residence and the date that you will be returning.

14. Door / Alarm Code(s)

    If you have a security alarm system or electronic door locks, this is where you would enter the code(s) to allow police/fire access in case of an emergency.

16. Emergency Contact First Name*
17. Emergency Contact Last Name*
18. Emergency Contact Phone Number*
20. Location of any extra or hidden keys
22. Will any vehicles be left at residence?*

    1. YES
    2. NO
23. Description of vehicles that will be parked at residence.

    Example: 2018 Ford Explorer, blue with black trim.

25. Will any animal/pets be left at residence or in the yard?*

    1. YES
    2. NO
26. Description of animal/pet(s) that will be left at residence or in the yard.

    Example: Tony, 9 yr old Boston Terrier, black and white. Trixie, 3 yr old Calico cat, orange and white.

28. Will any lights be left on or on a timer?*

    1. YES
    2. NO
29. Location of lights left on while away

    Example: Carport light will be on. Front living room lamp is on a timer and will be on from 6pm until 11pm.

31. Include any additional pertinent information

    Example: My brother, Jason Simmons, will be checking my mail and property. I have my lawn mowed on Wednesdays by ACME Landscapers.

33. Disclaimer:

    Emergency contact information is required.  Please, have someone pick up your mail and packages, or have the service stopped.  The Havelock Police Department is not responsible for your  home and only offers this service as a courtesy.  The Havelock Police Department cannot guarantee that your home will be checked every day.  Any request longer than thirty (30) days will only be checked weekly.  If you return home prior to the date listed above, please contact the Police Department and notify them of your return.

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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field