2. Complete all fields:
4. Name:*
6. Address:*
8. Contact Number 1:*
9. Contact Number 2:*
10. Contact Number 3:*
12. Date leaving:*
13. Date Returning:*
14. Are House Lights on a timer?*
    -- Select One --YesNo
16. Vehicles on Site (Make/ Model):*
18. Local Contact Name:*
20. Local Contact Phone Number:*
22. Comments:
24. The homeowner understands that the Waite Park Police Department does not assume any liability for loss or damage to the property during the specified dates. The homeowner also understands that there is no guarantee that extra patrol will be done daily.
26. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature*
29. Date:*
    Date:
31. NOTICE: THE EXTRA PATROL REQUESTS WILL ONLY BE ENTERED DURING NORMAL BUSINESS HOURS.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field