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2. Contact and Home Details
4. Name*
6. Address*
8. Home Phone
9. Cell Phone
11. 
13. Departure Date*
    Departure Date
14. Return Date*
    Return Date
16. Code / Password*
    This will be used to verify your identity in the event you need to change information or authorize police actions on your behalf.
18. Your Emergency Contact Information
20. Where Else Can You Be Reached? (Phones)*
22. Where Are You Traveling To? (Address)
24. What Email Address Do You Check Regularly?
26. Is Your Home Alarmed?*

    1. Yes
    2. No
27. If Yes, Who Is The Alarm Company?
29. Designated Emergency Contact List
    List the individuals you have selected as emergency contacts while you are away. These people should 1. Know your plans 2. Be able to respond to your home with a key. 3. Know how to reset your alarm. 4. Know when something is suspicious that needs attention. We will contact the individuals you have designated in the order you have listed them, starting with the 1st Contact.
31. Contact #1
33. Name
34. Phone Number
36. Contact #2
38. Name
39. Phone Number
41. Contact #3
43. Name
44. Phone Number
46. People Authorized To Be At Your Home
    Please list the names and type of relationship for all other people expected to stop by the home. These are known individuals who are not considered as a primary contact. (example; lawn care provider, maintenance worker, pet sitter, designated person to pick up mail or newspaper)
48. Name
49. Contact Nature
51.  
52.  
54.  
55.  
57.  
58.  
60.  
61.  
63.  
64.  
66. Pet Information
    Please describe the pets that may be left in the home. Include the type of animal (cat, dog), the pets name, breed, color, collar or chip information, disposition of the animal (aggressive?)
68. Pet Details
69. Will Pets Have Access To Secure Areas Such As The Back Yard?

    1. Yes
    2. No
71. Vehicle Information
    Please describe any vehicles that are left behind while you are away, or any vehicles used by individuals who may stop by your residence for other reasons. That may include relatives, house-sitters, cleaning service, yards care service, pool-care company, and so on.
73. Vehicle #1
75. Make
76. Model
77. Color
78. License Plate #
80. Vehicle #2
82. Make
83. Model
84. Color
85. License Plate #
87. Vehicle #3
89. Make
90. Model
91. Color
92. License Plate #
94. Vehicle #4
96. Make
97. Model
98. Color
99. License Plate #
101. Vehicle #5
103. Make
104. Model
105. Color
106. License Plate #
108. Special Instructions
     The text box below allows you the opportunity to provide additional information not covered so far. This can include information that describes what lights may be on timers inside the home, how mail or newspapers are being collected and by whom, previous damage to a particular window or door, or any other information that you feel is important for us to know.
110.  
112. Authorization
     I hereby request members of the Lafayette Police Department to perform random House Security Checks on my residence during my absence. The information contained herein is accurate to the best of my ability. I agree to notify the Lafayette Police Department immediately upon my return. I give permission for Lafayette Police Officers to enter my property to conduct a security check of my property, and to enter the residence if exigent circumstances are present. (Example: found open door or window, evidence of a burglary, investigation of an alarm etc) I understand that the Lafayette Police Department will make every effort to keep my residence secure, and I agree that there is no crime prevention strategy that is absolutely effective against all crime. This Security Check is part of a layered approach to crime prevention and I agree other steps should be taken on my behalf. I hereby hold harmless, the Lafayette Police Department, of any circumstance beyond their control, which may result in damage to my property.
114. Name*
115. Date*
     Date
117.  *

     1. Check Box If Lafayette Police Department Is Authorized
Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit Submit and Print

* indicates a required field