2. Instructions
   Please complete and submit the form below. We ask for five business days notice. An officer from the Coralville Police Department will contact you to confirm we've received your request. Note: Information submitted on this form will be sent to the Coralville Police Department via email. To protect sensitive information, do not provide the following information on this form: Social Security or driver’s license numbers, bank account information, medical information, passport numbers, and passwords.
3. 
7. Resident Information
9. Address*
10. Phone*
12. First Name*
13. Last Name*
15. Departure Date & Time*
    Departure Date & Time

    Departure Date & Time
16. Return Date & Time*
    Return Date & Time

    Return Date & Time
17. Is this your*

    1. Residence
    2. Business
21. Have keys been left with anyone?*

    1. Yes
    2. No
23. If so, who?
24. What is their phone number?
28. Will someone be working at or have access to the premises?*

    1. Yes
    2. No
30. If yes, who has access?
31. Why will they be there?
32. What's their vehicle?
34. If yes, who else has access?
35. Why will they be there?
36. What's their vehicle?
40. Will any vehicles be left in driveway/carport?*

    1. Yes
    2. No
41. License Plate No(s).
43. Will any lights be left on in the premises?*

    1. Yes
    2. No
44. Timer
45. Location
47. Do you have an alarm?*

    1. Yes
    2. No
48. Alarm Company
50. Will any animals be left on or in the premises?*

    1. Yes
    2. No
51. Type(s)
55. Emergency contact by collect call (if desired)
56. Phone
60. Name of person submitting form*
61. Email*
63. Please Review*

    Vacation security home checks will be conducted as time permits by the Coralville Police Department. By submitting this form, I release the Coralville Police Department of all liability for any loss or property damage occurring during this time period.

    1. I understand and agree to the above.
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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field