Waterville Police Department

                                       Request for Security Check

Name: Address:  

Phone:

Date leaving: Date returning:   

Reason for check: (check one) Vacation    Vacant    Extra Eye 

     Yes  No    If yes: Name:     Phone: 

Will a dog or other animal be left on premises?  Yes    No

Will anyone be working about or have access to premises during your absence?  

     Yes    No 

     If yes - Names: 

In case of emergency do you wish to be notified by collect call?  Yes    No 

     Name:    Phone: 

Will a night light be left on?  Yes    No    Timer    Times 

     If yes, where?