Munford Police Department REQUEST FOR SECURITY CHECK
NO. _______________________

ADDRESS ___________________________________________ NAME ___________________________________ PHONE NO.__________________

DEPARTURE DATE________________________________________RETURN DATE____________________________________________________

PROBABLE ROUTE OF TRIP__________________________________________________________________________________________________

TYPE PREMISES RESIDENCE ( ) BUSINESS ( ) OTHER ( )_________________________________________________________________________

HAVE KEYS BEEN LEFT WITH ANYONE? YES ( ) NO ( )

IF YES, NAME ________________________________________ADDRESS _______________________________ PHONE NO. __________________

WILL ANYONE BE WORKING ABOUT OR HAVE ACCESS TO PREMISES DURING YOUR ABSENCE? YES ( ) NO ( )

IF YES, NAMES _______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

IN CASE OF EMERGENCY DO YOU WISH TO BE NOTIFIED BY COLLECT CALL? YES ( ) NO ( )

C/O NAME_____________________________________________ADDRESS________________________________ PHONE NO.___________________

I REQUEST A SECURITY CHECK BE MADE OF MY PREMISES AND AGREE TO NOTIFY YOU OF MY RETURN.

SIGNED ________________________________________________________________________ DATE OF REQUEST _________________________

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OFFICER'S SECURITY CHECK REPORT

DATE	TIME	STATE IF PREMISES WERE SECURE OR OTHER*	OFFICERS INITIALS

*IF PREMISES WERE UNSECURE OR EVIDENCE OF FORCED ENTRY PRESENT STATE IF YOU ENTERED AND CHECKED PREMISES.
IF YOU FOUND ANY EVIDENCE OF VANDALISM OR THEFT MAKE SEPARATE REPORT.