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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

VacationEmergencyOther Invalid Input

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

Residence Invalid Input

Is anyone checking your house other then the Police

yesno Invalid Input

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

yesno Invalid Input

If so, describe (Make, Model, Color, Registration Number)

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Any lights left on

yes no Invalid Input

Are they on a timer

yesno Invalid Input

What time do they turn on and off

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Any Firearms left in the house

yesno Invalid Input

How many

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In what room

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Is premise a business

yesno Invalid Input

Will Business be posted as being closed

yesno Invalid Input

Any lights left on

yes no Invalid Input

Are lights on a timer

yesno Invalid Input

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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Last Updated: 18 April 2018

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