Request Number:______________ Request Date: __________________ Request Taken By: __________________
Your Name: _______________________________________________________________________________________
(Last) (First) MI
INFORMATION ABOUT YOUR HOME & VEHICLES
Address: _____________________________________________ Subdivison: _________________________________
Your Telephone Number: ______________________________ Is there rear access? Y___ N___
The home will be vacant from: _____________________ (mm/dd/yy) Until: ____________________ (mm/dd/yy)
Number of vehicles that will be parked at the home: ____
Veh 1: _____________________________________________ License Number: ___________________
Make, Model, Color, & Year State Number
Located in: ____ Garage ____ Driveway ____ Street
Veh 2: _____________________________________________ License Number: ___________________
Make, Model, Color, & Year State Number
Located in: ____ Garage ____ Driveway ____ Street
HOW CAN WE REACH YOU
Where are you staying? _____________________________________________________________________________
Address City State Zip
Additional Phone No: ___________________________ Cell Phone No: ______________________________
LOCAL CONTACT(S)
Cell
1. Caretaker’s Name: ______________________________ Phone No: ______________ Phone No: ______________
Caretaker’s Addr: _________________________________________________________________________________
Address City State Zip
Cell
2. Caretaker’s Name: ______________________________ Phone No: ______________ Phone No: ______________
Caretaker’s Addr: _________________________________________________________________________________
Address City State Zip
If packages are delivered, who would you like us to contact.
Contact: _________________________________________________________________________________
Name Phone number
Alarm Company Name: ________________________________________________ Phone No: ____________________
I hereby authorize home checks to be conducted in my absence. I understand and acknowledge that a request for a vacation home check pursuant to
this program does not guarantee the safety or security of my property. I further acknowledge that the Town of Sahuarita is in no way responsible for my
property in my absence and that Sahuarita VIPS and the Sahuarita Police Department may visually and/or inspect my premises during their patrols.
Signature X ______________________________________________ Date ___________________________________
Police Department
VACATION CHECK FORM
