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2. Date Leaving - Date Returning
   Date Leaving - Date Returning Start Date

   —

   Date Leaving - Date Returning End Date
4. Name / Owner
6. Address
8. City
9. State
10. Zip Code
12. Are you reachable by a cell phone while gone?
14. Is there a pet left on premises?

    1. Yes
    2. No
15. Where will the pet be left?

    1. Inside
    2. Outside
    3. Both
17. Do you have a security alarm?

    1. Yes
    2. No
19. Name of Alarm Service
20. Phone
22. Will lights be left on a timer?

    1. Yes
    2. No
23. Times and Locations
25. Is there current damage to your home's windows, doors or fence?

    1. Yes
    2. No
27. Where?
29. Any vehicle(s) left in the driveway?

    1. Yes
    2. No
30. Note the license plate number(s)
34. Person(s) Checking Property
36. Name
38. Address
40. City
41. State
42. Zip Code
44. Checking

    1. Daily
    2. Periodically
45. Authorized to enter residence?

    1. Yes
    2. No
47. Vehicle Description(s)
51. Name
53. Address
55. City
56. State
57. Zip Code
59. Checking

    1. Daily
    2. Periodically
60. Authorized to enter residence?

    1. Yes
    2. No
62. Vehicle Description(s)
66. I hereby give consent to the Cottage Grove Police Department to enter my property during the time indicated in my absence for the purpose of inspection to ensure property is secure and further authorize identification / verification to their presence or permission to be there.
68. eSignature
69. Date
    Date
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71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

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