City of College Park
Premise/Vacation Check Request
Submit Completed Form via email to publicservices@collegeparkmd.gov
Address
________________________________________ College Park, MD 20740
Single Family Home Town House Condo Business
Requested By
_____________________________________________
Owner Tenant Other ________
Departure Date/Time
_____________________
Return Date/Time
______________________________
Yes No How Many _____________
License No. _____________________________
Make/Model _________________________
License No. _____________________________
Make/Model _________________________
Does anyone have keys?
Yes, premise only; Yes, premise and vehicle No
Name:
______________________________________________________________________________
Address:
____________________________________________
Phone No.: ______________________
Will anyone be working at or have access to the interior of premises during your absence? Yes No
Name:
___________________________________________________________________________
Address:
_____________________________________________
Phone: ________________________
Will anyone be working at or have access to the exterior of premises during your absence? Yes No
Name:
______________________________________________________________________________
Address:
_____________________________________________
Phone: _______________________
Do you have an alarm company? Yes No
Company Name:
__________________________________________________________________________
Address:
_________________________________________
Phone: _______________________
Emergency Contact (local or where to reach you when you’re away)
Name:
______________________________________________________________________________
Address:
_____________________________________________
Phone: ________________________
Will you be leaving any lights or appliances on a timer? Yes No
Location(s)
Living/Dining Room Kitchen Upstairs Front Upstairs Back
Any special conditions or comments? ________________________________________________________
Helpful Hints
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By submitting this request I acknowledge that I am an owner or tenant or authorized party of the address provided above and
have informed the Prince George’s County Police Department through City of College Park Contract Police Program of my
intention to be away for the period entered. Further, I understand that this request will not substitute for security measures,
which I have the responsibility to exercise. In the event that I return to the property prior to the return date, the appropriate
parties will be notified. Officers will attempt to visit the premises daily for the duration of my absence unless circumstances
arise to preclude such inspection.
_______________________________________________ _____________________
Signature Date
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