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2. Niceville Police Department House Check / Extra Patrol
4. Name*
5. Phone Number*
7. Address*
9. Reason for Extra Patrol:*

   1. Premise will be Vacant
   2. Other
10. If other, please explain:
14. Keys left with anyone?*

    1. Yes
    2. No
16. Name
17. Phone
19. Address
21. Do you wish to be contacted collect?*

    1. Yes
    2. No
22. Phone
26. C/O Name
28. Address
30. Other persons allowed on premises:*
34. Date of Departure & Return*
    Date of Departure & Return Start Date

    —

    Date of Departure & Return End Date
35. Animals left of premises?*

    1. Yes
    2. No
36. Location
38. Any vehicle left in boat/yard?*

    1. Yes
    2. No
39. Description and location
43. Protected by alarm system?*

    1. Yes
    2. No
44. Alarm Company Name
46. Lights?*

    1. Constant
    2. Automatic
    3. Neither
47. Location of Lights
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I Agree
53. Electronic Signature*
    I request a security check be made of my premises during the dates listed above and will notify you upon my return.
54. Date of Request*
    Date of Request
56. Additional Comments
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field