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 Information Below: (A * indicates that the field is required)
* Your name:
Street address:
Street address (Cont).
City:
State:
Zip Code:
* E-mail address:
Telephone number:
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 person(s):
Vehicles they drive:
Do you have vehicles left in the driveway? If so, describe them.
Do you have timer lights?	Yes	No
If there are timer lights, what areas of the house are they located?
Are there animals in the house?	Yes	No
Please provide any other information we should have.
Additional Information: