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Vacation Watch Form

Vacation house checks will be limited to a maximum of two (2) months. Security checks of vacant residences will be limited to a maximum of one (1) month. Either residence check may be reinstated for one (1) additional month at the termination of the initial time period.
First Name*
Last Name*
Select One*
1. Owner
2. Renter
3. Manager
Phone Number*
Address*
Departure Date*
Departure Date
Return Date*
Return Date
Type of Premises (Select One)*
1. Residence
2. Business
3. Other
If Other, Please Describe Premises*
Type of Check to be Done (Select One)*
1. Spotlight
2. Physical
3. Both
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In case of emergency, we will attempt to contact the persons you list below. An emergency contact should be someone who can respond to the home or business, day or night, with a key and/or access to the alarm system if needed. Please provide the name and phone number of two contacts.
Name*
Address*
Phone Number*
Name*
Address*
Phone Number*
Will the above listed have keys to property? (Select One)*
1. Yes
2. No
If yes, who?*
In case of an emergency, do you wish to be notified by phone? (Select One)*
1. Yes
2. No
If yes, at what phone number?*
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Will lights be left on? (Select One)*
1. Yes
2. No
If yes, what rooms?*
Will any pets be left at home? (Select One)*
1. Yes
2. No
If yes, where will they be kept?*
Will anyone be entering or working around the residence or business while you are gone? (Select One)*
1. Yes
2. No
If yes, enter their name and purpose.*
Do you have an alarm at your residence? (Select One)*
1. Yes
2. No
If yes, enter name and phone number of alarm company.*
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I request a security check be made of my premises and I agree to notify the Burlington Police Department upon my return. I understand that the frequency of the security checks will depend on other calls for service and enforcement activities of the patrol officers. I understand that the Burlington Police Department cannot guarantee the frequency of the security checks. I agree to hold harmless the Burlington Police Department, the City of Burlington, and its employees, agents, and representatives for any damage to or criminal offense upon my premises.
Electronic Signature*
I understand that by typing my name, it is equal to my physical signature and I authorize the Burlington Police Department and City of Burlington to use my electronic signature as they would my physical signature.
Date*
Date

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