2. Complete all fields:
4. Name:*
5. Address:*
7. Contact Number 1:*
8. Type of Phone 1*
10. Contact Number 2:
11. Type of Phone 2
13. Email Address
15. Date leaving:*
16. Date Returning:*
17. Are House Lights on a timer?*
    -- Select One --YesNo
19. Vehicles on Site (Make/ Model):

    This helps us to determine if a vehicle that is on site should be there or not. 

21. Local Contact Name:

    Someone who would have access to your home, may be checking on your home while you are gone or could contact you in an emergency. 

22. Local Contact Phone Number:
24. Comments:
26. 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.
28. 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.
30. Electronic Signature*
31. Date:*
    Date:

33. NOTICE: OFFICERS WILL ONLY BE NOTIFIED OF EXTRA PATROL REQUESTS DURING NORMAL BUSINESS HOURS.

    If you have any questions, contact Alicia Mages, Community Outreach Specialist at 320-251-7393 or alicia.mages@ci.waiteparkpd.mn.us

Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field