ACPD Patch COMMUNITY POLICING DEPARTMENT

HOUSE CHECK REQUEST
 

* Extra Patrol will take place ONLY when the sector officer is not responding to calls for service/other required duties. ACPD cannot be responsible for ensuring the safety of your home or family during your absence. You should take whatever steps you judge are necessary to keep your home safe during this period *

   

Please complete as much information as possible. Directions only needed if your location is new or requires additional instructions.

  * NAME:    * TELEPHONE: 
 (AAA-NNN-NNNN)
  * ADDRESS: 

   EMAIL: 
If you provide an email address, you will receive an acknowledgment of this request.
 
  * DEPARTURE DATE: 
(MM/DD/CCYY)
  * RETURN DATE: 
(MM/DD/CCYY)
 
PERSON(S) TO CALL IN THE EVENT OF AN EMERGENCY: 
 
  * NAME: 

 * HAS KEY? 

  * PHONE:  
(AAA-NNN-NNNN)
 
NAME: 

HAS KEY? 

PHONE:  
(AAA-NNN-NNNN)
 
  * ALARM SYSTEM? 
  * LIGHTS/TIMERS? 
   IF YES TO ALARM/TIMERS,
WHERE LOCATED?: 
 
  * Should there be anyone at your residence during this time frame? 
   If YES, who: 
Purpose:  
 
  * VEHICLE LEFT? 
IF YES:  Tag #: Make:
  Model: Color:
       
DIRECTIONS TO RESIDENCE: 
 
ADDITIONAL INFORMATION: 
 
       

Services Division
1600 5th Street, Suite D
Charlottesville, VA 22902