Vacation Check Request

Departure Date *

Month

Day

Year

Time of Departure *

Return Date *

Month

Day

Year

Time of Return *

Full Address of Property *

Name and Contact Information

First *

Last *

Email Address *

Phone Number *

Mobile Phone (you can be reached at while away) *

Alarm Information

Do you have an alarm service? *

Yes

Alarm Service Company Name and Phone Number

Please read the following statement before submitting this form. *

The Chenoa Police Department, per your request, will attempt to check your residence periodically. Neither the City of Chenoa, nor the Chenoa Police Department assume any liability in the event of theft, loss or damage to personal or real property in or around your residence. By submitting this form, it is understood and agreed that neither the City of Chenoa or the Chenoa Police Department assumes any liability with the "Vacation House Check." The resident, by accepting the "Vacation House Check," and by execution of this request understands and agrees to the provisions of this release.

I have read and understand the release and agree to its provisions.

I DO NOT agree to the provisions of the release.

Electronic Signature (type full legal name including first and last) *

Leave this field blank

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