2. Today's date:*
   mm/dd/yyyy
4. Waiver,
   I, the undersigned, affirm I am the owner of the property indicated and further agree to hold harmless the Village of Waunakee and the Village of Waunakee Police Department and its employees; acknowledging that by completing this form, I am requesting police check said property during my absence. Further, I affirm the property will be vacant during the times listed below.

   I further acknowledge this form in no way binds nor implies the Waunakee Police Department will be responsible for the security and safekeeping of my property. I understand that if the Police Department finds an open door, officers will enter my residence and check it.
6. Effective From:*
7. Effective To:*
9. Address:*
11. Owner Name:*
12. Home Phone:*
    (608) xxx-xxxx
14. Cell Phone:*
    (608) xxx-xxxx
16. Request made by:*
18. Type of premises:*

    1. Residence
    2. Business
    3. Other
20. Lights on:*

    1. Yes
    2. No
21. Constant:*

    1. Yes
    2. No
23. Light(s) Location(s):*
25. Keys left with anyone:*

    1. Yes
    2. No
27. Persons with Access to Premises - list name, address & phone number:
29. Address:
31. Phone number:
    (608) xxx-xxxx
33. How can you be reached (phone numbers and address):*
35. Notes
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field