Residence Check Request

Please provide the following information at least 72 hours before the service is needed.

The Conway Police Department offers this service to the citizens of Conway, Arkansas on a limited basis. Our patrol officers will check on your residence up to two times per day, when possible and circumstance allow. Any crime or property damage that may occur during your absence can not and will not be the responsibility of this department or city.

Address of residence to be checked Address of residence to be checked
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Person requesting residence check Person requesting residence check First Last
Primary Phone Number Primary Phone Number - ### - ### ####
Alternate Phone Number Alternate Phone Number - ### - ### ####
Email Address
Date of Departure Date of Departure / MM / DD YYYY
Time of Departure
Date of Return Date of Return / MM / DD YYYY
Time of Return
Local Contact Local Contact First Last
Local Contact's Phone Local Contact's Phone - ### - ### ####
Address of Contact Person Address of Contact Person
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Permissions
Permissions	Yes	No
Permission granted to enter back & side yards?	Permission granted to enter back & side yards?Yes	Permission granted to enter back & side yards?No
Is there a risk of an officer/pet encounter at the residence?	Is there a risk of an officer/pet encounter at the residence?Yes	Is there a risk of an officer/pet encounter at the residence?No
Will lights be left on in the residence? (Recommended)	Will lights be left on in the residence? (Recommended)Yes	Will lights be left on in the residence? (Recommended)No
Is a friend or neighbor picking up your newspaper and/or mail? (Recommended)	Is a friend or neighbor picking up your newspaper and/or mail? (Recommended)Yes	Is a friend or neighbor picking up your newspaper and/or mail? (Recommended)No
Will any motor vehicle(s) be left in driveway/garage?	Will any motor vehicle(s) be left in driveway/garage?Yes	Will any motor vehicle(s) be left in driveway/garage?No

Please list any areas of special concern.
I agree to not hold the Conway Police Department or the City of Conway responsible for any damage to or loss of property that may occur during my absence.