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___________________________________________________________________________________________
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N WADE ENGELHART
Established 1805 Chief of Police
BROOKLYN POLICE DEPARTMENT
VACATION/VACANT BUILDING CHECK
Departure Date: _______________________________ Return Date: __________________________________
Owner: ______________________________________ Home Phone: _________________________________
Address: _____________________________________ Cell Phone: ___________________________________
Request Made By:__________________________________________________________________________
Type of Premise: Business ________________ Residence ___________________ Other ________________
Protected by Alarm: No _________ Yes – Type __________________________________________________
Any Lights Left On: No _________ Yes – Constant? ____________ Automatic? _______________________
What Areas/Rooms are Lights Left On: __________________________________________________________
Keys Left with Anyone:
No ______ Yes – Name, Address, & Contact Number _______________________________________________
Any Vehicles Left in Driveway/Garage:
No______ Yes – Type & License ________________________________________________________________
Any additional persons with access to the premise. If so, please indicate name and contact number: ________
__________________________________________________________________________________________
__________________________________________________________________________________________
Where can YOU be contacted at in an emergency: _________________________________________________
___________________________________ _________________________
Signature of Owner Date Signed
Police@brooklynwi.gov www.brooklynwi.gov/police
BRPD-030
click to sign
signature
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