Security Check Request Form

	Emergency: 911 Office: (330) 824-2545 Fax: (330) 824-2135 1583 Salt Springs Road Lordstown, Ohio 44481

Security Check Request Form

Please complete the below form to facilitate a security check on your residence in your absence.

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Please Provide the Below Information:
* Enter Your Name:
Street Address:
Street Address (Cont).
City:
State:
Zip Code:
* Email:
Telephone No.:
Enter the date of departure :			*-- mm/dd/yy*
Enter the date of return :			*-- mm/dd/yy*
Names of anyone having access to premises during your absence and vehicle that they drive?
Names of Persons
Vehicles they Drive
Vehicles left in driveway?
Timer lights ?	Yes	No
If there are timer lights what areas are they located in ?

Are there animals in the house?	Yes	No
Please provide any other information we should have ?
Additional Information:


*A indicates a field is required**