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House Check Sign Up Form
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* Indicates required question
Resident's Name
*
Your answer
Address
*
Your answer
Email Address
Your answer
Home Phone Number
Your answer
Cell Phone or Emergency Contact
*
Your answer
Date Leaving: To be eligible for program your leave must be 72 hours (3 days) or more.
*
Please enter the date you will be leaving your home unattended.
MM
/
DD
/
YYYY
Date Return: To be eligible for program your leave must be 72 hours (3 days) or more.
*
Please enter the date you will be returning home.
MM
/
DD
/
YYYY
Key's Left With
(If Applicable; Please include Name and Contact Number)
Your answer
Cars In Drive
(make/model/color)
Your answer
Paper/Mail
Has this been stopped or is being picked up by someone?
Your answer
Lights
Please describe what lights will be on during your absence
Your answer
Anyone In/Out Of the Residence? To be eligible for program: The residence must be vacant for the duration of leave. If an individual is staying or coming into the home while the resident is away, the residence is not eligible for the program.
*
No - No one will be in/out of the residence while I'm away
Required
Alarm System & Company? Alarm System must be activated if the home is equipped, to be eligible.
*
If applicable what alarm company and what is their contact info?
Your answer
Additional comments or more information
Your answer
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