FOR EATONVILLE POLICE DEPARTMENT USE ONLY:
START DATE: ____________________________
END DATE: _____________________________
VACATION HOUSE CHECK REQUEST
EATONVILLE POLICE DEPARTMENT
The following person is authorized to enter and will be looking after my property or, to be
contacted in case of emergency:
This party has a key to the property:
The undersigned does hereby grant and request the Town and its Police Department to visually
check upon the property listed above. The undersigned does hereby agree to hold harmless the
Town, its employees and agents for any and all claims for personal injury, loss or damage to
property that may be suffered by the undersigned through any action or lack thereof by a
representative of the Town. Further, the undersigned understands and agrees that this is a
voluntary, free service, does not create a special duty upon the town, will be provided only as
time is available, and no guarantee is made nor assurance given against loss, theft or damage to
premises.
Signed this ______ day of _______________ 20______
_______________________________
PRINT NAME
SIGNATURE
Form: EPD-Vac Chk 07/09/2008
Date of Request:
Name: Phone Number:
Address:
Date Leaving: Date Returning:
Vehicle left on Premises:
License Plate:
License Plate:
Vehicle left on Premises:
Protected by Alarm System:
Yes
No
If yes, type of alarm:
Lights on: Constant?
Yes
No
Automatic?
Yes
No
I can be reached at: Name:
Phone Number:Address:
Name: Phone Number:
Address:
Yes No
Address:
Name:
Address:
Yes
Phone Number:
This party has a key to the property: No
