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2. Incident Number (Office Use Only)
3. Person Receiving Request (Office Use Only)
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Departure and Return Dates
    Departure and Return Dates Start Date

    —

    Departure and Return Dates End Date
14. Date Request Made
    Date Request Made
16. First Name
17. Last Name
19. Date of Birth
    Date of Birth
20. Telephone
22. Will anyone have permission to be on the premises?

    1. Yes
    2. No
23. If yes, who?
25. Will lights be left on?

    1. Yes
    2. No
26. If yes, where?
28. Does anyone have permission to use the driveway or garage?

    1. Yes
    2. No
29. If so, who?
31. Has the mail and/or newspapers been notified to stop delivery?

    1. Yes
    2. No
33. Is your residence protected by an alarm system?

    1. Yes
    2. No
34. If yes, company name and telephone number?
36. Will a neighbor be watching the residence?

    1. Yes
    2. No
37. If yes, who?
38. Telephone Number
40. Please notify the Police Department upon your return by telephone at 715-524-4545 or in person at the Police Station.
    I understand the Shawano Police Department makes no promises, assumes no risk or responsibility in checking your residence while the home is vacant. The Police Department will attempt to check your residence while you are away, but understand that other calls for service take precedence over this program.
42. Signature
    By typing your name into this field you authorize the Police Department to consider this an electronic Signature.
43. Date
    Date
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field