2. 
4. DAPHNE POLICE DEPARTMENT SECURITY CHECK FORM
6. Premise Type:*

   1. Residence
   2. Business
   3. Other
8. Applicant Name:*
10. Address*
12. Date of Departure*
13. Date of Return*
15. If Residence, do you have any pets at home?

    1. Yes
    2. No
16. If Yes, inside or outside pet?

    1. Inside
    2. Outside
18. Are you leaving keys with anyone?*

    1. Yes
    2. No
19. If Yes, please list name & contact number:
21. Will anyone be working there or have access to the premises during your absence (i.e. construction worker, landscaper, cleaning service, etc)?*

    1. Yes
    2. No
23. If Yes, please list name and contact number:
25. Contact 1 Name:
26. Contact 1 Phone:
28. Contact 2 Name:
29. Contact 2 Phone:
31. Contact 3 Name:
32. Contact 3 Phone:
36. In case of emergency, please designate if you wish to be notified or if you wish for someone else to be contacted on your behalf:
38. Notify me at Phone Number:
39. or email:
41. Designated Contact Name:
42. Phone:
46. I request a security check be made of my premises and agree to notify you of my return:
48. Digital Signature:*
49. Date of Digital Request:*
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field