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2. Start Date
3. End Date
5. Name
7. Address
9. City
10. State
11. Zip Code
13. Phone Number 1
14. Phone Number 2
16. Lights Inside/Outside the Home
18. Location 1
19. Location 2
21. Location 3
22. Location 4
24. Lights On or Off

    1. On
    2. Off
26. Vehicles Outside on Property (List)
28. Persons Allowed on Property (List)
30. Telephone Where Owner Will be Staying
32. Emergency Contact
34. Name
35. Phone Number
37. Does the contact have keys?

    1. Yes
    2. No
39. Agreement*

    I understand that by checking this box I am requesting that the Garden City Police Department make periodic checks at the above location while I am away. I understand the Garden City Police Department can make no guarantees that the location will not be damaged, burglarized, or otherwise harmed, even with the additional patrols. I hereby hold the Garden City Police Department harmless for any incidents that my occur. I understand that checks will be made as Police manpower allows.

    1. I understand
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field