Security check request form

Please try to send this form 24 hrs prior to your departure.

Your Name (required)

Your Email (required)

Your Home Address (required)

Your Home Phone(required)

Your departure date (required)

Your return date (required)

Address where you will be staying

Phone number you can be reached at where you are staying (required)

May we call you collect in the event of an emergency?
Yes No 

Name of a local keyholder:

Local keyholder phone number:

Will someone be checking your residence? ie:feed animals, water plants etc
Yes No 

If yes, who?

What are their responsibilities?

Will anyone be performing work in or on your residence while you are away?

Yes No 

If yes, who?

Work to be performed?

Please list any vehicles that will be left at your residence:
Please provide make, model and color for each vehicle

Have any lights been left on timers?
Yes No 

Operating hours:

Will an Alarm System be in operation?
Yes No 

Alarm Monitoring Company:

Alarm Monitoring Phone Number:

Other special information you wish to provide:

I authorize the Columbiana Police Department to make security checks of my residence during my absence for the above listed dates. I agree to notify (by phone or in person) them immediately upon my return home. I also understand that should a door/window be found open, Officers will be entering my home to check for prowlers/damage.

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Contact Us

Columbiana Police Department
28 South Vine Street
Columbiana OH 44408
Phone 330-482-9292