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Vacation Check

Vacation Check Request Form

Request Date:

Date Leaving:

Date Returning:

RESIDENT

Resident:

Address:

ER Contact #:

E-Mail Address:

DESTINATION

Destination:

In Case of Emergency,
Notify: Phone #:

RESIDENCE

Outside Lights: Yes No     Timer: Yes No
Times:

Inside Lights: Yes No      Timer: Yes No
Times:

Alarm: Yes No      Timer: Yes No      Audible: Yes No      Silent: Yes No

Alarm Company:  Phone #:

VEHICLES LEFT ON PREMISES

Make: Model: Year:
Body: L/P:

Make: Model: Year:
Body: L/P:

Make: Model: Year:
Body: L/P:

PERSONS ALLOWED ON PREMISES

Name: Phone #:

Name: Phone #:

Name: Phone #:

MISCELLANEOUS INFO

I agree to allow the Willow Park Police Department to inform the Willow Park Water Works
that I am on vacation in the event of imposed water rationing. Yes No

Resident Signature:  Date:



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