Out of town, extra patrol form.

We will check your residence daily while you are out of town. 

This service is free of charge to City residents. 

Request forms are available at the office, or you can submit your request using the form below.

Fields marked with an asterisk ( * )  are a required field!

First Name *
Last Name *
Address *
Work Phone	xxx-xxx-xxxx
Home Phone *	xxx-xxx-xxxx
E-mail	[email protected]

Please enter the following information

Emergency contact:    

Cell Phone Number:    (xxx-xxx-xxxx)

Does the emergency contact have a key and alarm codes?        

Enter the date you are leaving town:

 * -- mm/dd/yy            -- Approximate Time 

Enter the date you are due back :

 * -- mm/dd/yy            -- Approximate Time

Select any of the following options that apply:

My house has an alarm.                          

If you check the door you may set off my alarm.  

I have left a window partly open.   Number of open windows              

I have a landscape company.

Company name				Contact person				Phone number	(xxx-xxx-xxxx)

Schedule:

                  
I have a maid service.  

Company name				Contact person				Phone number	(xxx-xxx-xxxx)

Schedule:      

I have a pool service.    

Company name				Contact person   			Phone number	(xxx-xxx-xxxx)

Schedule:     

My back yard is fenced.                          

I have a dog inside the fence

It is O.K. to enter my fenced yard.              

I will be leaving a radio on.                    

I will be leaving a light on.  Number 

Please list any vehicles you will be leaving in the driveway.

Please enter any special instructions in the box below.

How would you rate The Jefferson Police Department?

(1 = poor, 5 = excellent) 

1 2 3 4 5

Enter the following text in the box below*

QXTROMT