Name:

Address:

Type of Premises:            Business     Residence     Other

Reason for extra patrol:

Protected by Alarm:    Yes    No

Alarm company Name and Phone Number

Lights On:  Yes    No    Constant:    Yes    No    Automatic:    Yes    No

Location of Lights (Interior and Exterior):

Keys left with anyone:    Yes    No

Key holder Name, Address, and Phone Number:

Vehicles that might be at premises:

Dogs on Premises:     Yes    No

Electricity on:    Yes    No            Power Company:   

Other Person(s) with Access to Premises (Relatives, Employees, Neighbors, etc...)

If an Emergency, do you wish to be notified by collect call:     Yes    No

If so, Phone Number:   

Address where you can be contacted:

I request that a security check be made on my premises from

  to 

and I will notify you upon my return.

Name (Signature):   Date of Request:

E-mail Address (required for verification): 

Form will be sent to the Tuscarora Township Police Department, and you will receive verification that the request form has been
received via e-mail for verification of the information received.