Chesterfield Twp. Police Department Check of Premises Request

Please complete this form in it's entirety.
Today's Date
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Name
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Address
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Phone Number
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Email Address(*)
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Reason for request
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Date that you are leaving
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Date that you are returning
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In Case of Emergency Contact: Name
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Address
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Telephone Number
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Check if Premise is a Residence
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Is anyone checking your house other then the Police
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If so, Name of Person
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Address
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Phone Number
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Any Vehicles Left on the Premises
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If so, describe (Make, Model, Color, Registration Number)
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Any lights left on
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Are they on a timer
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What time do they turn on and off
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Any Firearms left in the house
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How many
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In what room
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Is premise a business
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Will Business be posted as being closed
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Any lights left on
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Are lights on a timer
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If so, what time do they turn on and off On at
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Alarm Information
Name of Alarm Company
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Telephone Number of Alarm Company
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Additional Comments or Information
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anti spam(*)
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