Henniker Police Department

Vacant House Check Information Form

Residents Name:__________________________________________________

Address:__________________________ Color:________________________

Date Leaving:_________________ Date Returning:_____________________

Location:___________________ Phone #:____________________________

Location of lights left on:_____________________________________________

Are lights on a timer? _____ Yes _____ No

Is house alarmed? _____ Yes _____ No

Vehicles in yard? _____ Yes _____ No

Plate#:___________Make:__________Model:__________Color:________

Plate#:___________Make:__________Model:__________Color:________

Vehicles in Garage? _____ Yes _____ No

Plate#:___________Make:__________Model:__________Color:________

Plate#:___________Make:__________Model:__________Color:________

Emergency Contact Person:____________________Phone #:__________

Anyone else with permission to be at your residence:

Name:______________________________________________
Reason:____________________________________________

Name:______________________________________________
Reason:____________________________________________

Date Received:______________