First Name

Last Name

Color of House

Address to be checked

Home Phone

Is house number visible from street? Yes No

If not, how can we identify your house

Date and Time Leaving

Date and Time Returning

Person(s) caring for your home while you are away or emergency contact

Name #1	Phone	Keys to property Yes No
Name #2	Phone	Keys to property Yes No
Name #3	Phone	Keys to property Yes No

I will be at

Phone

Lights left on Yes No

Where

Drapes Open Closed

Animals Yes No

If yes, what type of animals

Alarm Yes No

If yes, Company

Vehicles left on property Yes No

Vehicle #1 Year

Vehicle #1 Make

Vehicle #1 Color

Vehicle #1 License

Vehicle #1 Location Garage Driveway Yard Street

Vehicle #2 Year

Vehicle #2 Make

Vehicle #2 Color

Vehicle #2 License

Vehicle #2 Location Garage Driveway Yard Street

Vehicle #3 Year

Vehicle #3 Make

Vehicle #3 Color

Vehicle #3 License

Vehicle #3 Location Garage Driveway Yard Street

Other Comments

Please arrange for mail and newspaper pick-up. You authorize the Brandenburg Police Department to have officers, or members of the Citizens On Patrol, enter my property and visually inspect the house exterior. Should an open entry be found, you authorize the police to enter my house for further inspection. The police will endeavor to secure the house and contact the owner or person caring for the house that is listed above. You understands and agree that this is a voluntary, free service and does not create a special duty upon the City, and will be provided depending upon weather and available time. No guarantee is made nor assurance given against loss, theft or damage to the premises. You agree to hold harmless the City, its employees and agents for any and all claims for personal injury, loss or damage to property that may be suffered through any action or lack thereof by a representative of the City. PLEASE CALL THE POLICE DEPARTMENT AT 422-4981 WHEN YOU RETURN.