PELHAM

POLICE DEPARTMENT

14 VILLAGE GREEN

PELHAM NEW HAMPSHIRE 03076

Telephone (603) 635- 2411  Fax (603) 635-6959

Chief of Police

EVAN E.J. HAGLUND

VACANT HOUSE CHECK

*** Valid for no more than 30 days ***  

Please print. Completed forms can be dropped of at the Pelham Police Station 24 hours a day.

NAME:___________________________________________________________________________________

ADDRESS:________________________________________________________________________________

HOME PHONE: _____________________________________

DATE LEAVING: ____________________________________

DATE RETURNING: _________________________________

WHO SHOULD BE CALLED IN CASE OF EMERGENCY?_________________________________

DESCRIPTION OF HOUSE:_________________________________________________________________

WHO IS AUTHORIZED TO BE ON THE  PROPERTY?  PLEASE INCLUDE THEIR LICENSE PLATE NUMBER AND VEHICLE DESCRIPTION:

ARE YOU LEAVING ANY VEHICLES IN THE DRIVEWAY? (PLEASE DESCRIBE)

ARE YOU LEAVING ANY VEHICLES IN THE GARAGE? (PLEASE DESCRIBE)

LIGHTS ON TIMER?                  YES _____   NO ______

LIGHTS ON ALL THE TIME?   YES _____ NO _____

ANY OUTSIDE LIGHTS?            YES _____ NO _____

ARE YOU LEAVING ANY PETS HOME?  IF SO, PLEASE NOTE TYPE OF PET AND WHERE THEY WILL BE LOCATED.

IF HOUSE IS ALARMED, WHAT TYPE OF SYSTEM?

HONEYWELL _____     ADT _____     CENTRA-LARMS  _____   OTHER _____

ALARM COMPANY PHONE NUMBER: __________________________________________

YOUR SIGNATURE: _________________________________________________________

To be filled out by Police Department:

DATE AND TIME RECEIVED __________________________

RECEIVED BY DISPATCHER __________________________

DATE TYPED ______________________________________

TYPED BY DISPATCHER _____________________________