Collierville Police Department Vacation Check Request Form

Collierville Police Department

Vacation Check Request

If you live within the Collierville Town Limits, and you are going on vacation and you would like for the Collierville Police Department to conduct routine security checks of your residence, please notify the department by submitting the following form. You will be notified by e-mail when the Collierville Police Department receives the request. It may take up to 48 hours to process the application.
(Please use the tab button to advance from one field to the next, hitting return automatically submits the form.)

Security Check Report

Date/Time Leaving: Date/Time Returning:
Address:
Name:
Home Phone: Cell Phone:
E-mail Address:

Do you have an Alarm Service? Yes No
Alarm Co. Name & Phone:

Lights: On? Off?
Timer? On? Off?

Newspaper / Mail Stopped? Yes No

Doors / Windows locked? Yes No

Pets?
Inside the residence? Yes No
Outside the residence? Yes No

Description of all vehicles left on property

Will anyone be around the home? Yes No
If yes, who:

Contact Information where you can be reached
Location:
Address:
City/State/Zip
Phone:
In case of emergency - Do you wish to be notified by COLLECT CALL? Yes No

Local Emergency Contact Person
Name:
Address:
City/State/Zip:
Phone:
Does emergency contact have keys to residence? Yes No

If keys left with anyone else please list name, address, and telephone

Comments:

Please read the following before submitting to this form.

The Collierville Police Department, as per your request, will check your residence periodically. Neither the Town of Collierville, nor the Collierville Police Department assume any liability in the event of theft, loss or damage to personal or real property in or around your residence. By pressing the submit button, it is understood and agreed that neither the Town of Collierville or the Collierville Police Department assumes any liability with the "Vacation House Check". The homeowner by accepting the "Vacation House Check", and by execution of this request understands and agrees to the provisions of this release.