Once this form is completed, please mail it to the Pelham Police Department at least 5 days prior to

your planned departure. If mailing the form is an inconvenience, you can simply drop off your request

at the station. Please fill out form completely.

Date:

Chief of Police

Pelham Police Department

14 Village Green

Pelham, NH 03076

Dear Sir,

I am requesting that the Pelham Police Department make periodic visits to my property and to

enter my home and all buildings on my property while I am away during the period of:

Departure Date: _________ through the Return Date: _________

A description and location of the property is: ____________________________________________

________________________________________________________________________________

________________________________________________________________________________

Property owner concerns:___________________________________________________________

_______________________________________________________________________________

Should the Pelham Police Department become aware of any violations of the law on my property, I

request that they take whatever legal action they feel is necessary.

Persons who have permission to enter the above mentioned property are: ____________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Sincerely,

___________________________________

Property Owner                                                        Emergency contact phone#___________________