Form Center

2. Street Address
4. City
5. Gate Code
7. Vacation Check Date Span
   Vacation Check Date Span Start Date

   —

   Vacation Check Date Span End Date
11. Personal Information
13. First Name
14. Last Name
16. Phone
17. Email
21. Emergency Contact
23. First Name
24. Last Name
26. Address
28. Phone Number
32. House Details
34. Nearest cross street
35. House color
37. Is your address visible on the house?

    1. Yes
    2. No
38. If no, describe the house number location.
40. Are there any outbuildings?

    1. Yes
    2. No
41. If yes, describe the buildings.
43. Are all your doors and windows locked?

    1. Yes
    2. No
45. Do you have any pets?

    1. Yes
    2. No
46. Were any lights left on?

    1. Yes
    2. No
48. Have you stopped your mail?

    1. Yes
    2. No
49. Is there a house alarm?

    1. Yes
    2. No
51. Do you have Yard/Pool Services?

    1. Yes
    2. No
52. Are there vehicles left on the property?

    1. Yes
    2. No
56. Please list persons authorized on your property.
58. Does anyone have keys to the home?
60. Additional Information
62. Agreement*

    In your absence, the Placer County Sheriff Volunteers will provide periodic security checks of your property. They will immediately report any suspicious activity to patrol deputies to investigate.
    
    A vacation check will be valid for no longer than thirty days at a time. Each time you are requesting a vacation check for your home you must fill out and submit a new vacation check form.
    
    Vacation checks are only provided on the weekdays, during normal business hours. Checks are not provided on the weekend unless staffing is available.

    1. I agree
    2. I do not agree
64. Date
    Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field