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VACATION WATCH / VACANT HOUSE REGISTRY

2. Waiver
   I, the undersigned, affirm that I am the owner/ legal occupant of the property indicated, and further agree to hold harmless the City of Verona Police Department and any of its agents or representatives, acknowledging that by completing this form and filing the same with the City of Verona Police Department, I am requesting that a record be maintained that said property will be vacant during the times listed below. I further acknowledge, the filing of this registration in no way binds or implies that the City of Verona Police Department will be responsible for the security and safekeeping of my property.
4. Accept and Continue*

   1. I accept the terms of this waiver.
8. Owner/Occupant First Name
9. Owner/ Occupant Last Name
11. Request Made By:*
13. Effective From/To:*
    Effective From/To: Start Date

    —

    Effective From/To: End Date
    Select the starting and ending dates of your request.
15. Street Number*
16. Street Name*
17. Apt / Suite / Unit #
18. Home Phone Number
20. City, State*

    (Addresses outside the City of Verona cannot be submitted to the City of Verona Police Department.)

    1. I confirm that my address is in the City of Verona, Wisconsin.
22. Type of Premises*
    -- Select One --BusinessResidenceOther
24. Describe "Other"
    Description of Premises
26. Protected by Alarm System*

    1. Yes
    2. No
27. Alarm System Type/ Company Name
29. Lights On Within Residence?*

    1. Yes
    2. No
30. Lights are

    1. On Constantly
    2. On Timer(s)
32. Light Locations
    Describe locations of lights being left on within home; i.e. "upstairs bedroom, over kitchen sink," etc.
34. Vehicle(s) in Driveway / Parking Lot?*

    1. Yes
    2. No
35. Vehicle Description
    Describe make and model of vehicles in the driveway (include license plate numbers, if applicable).
37. Does Anyone Have Access to Your Residence While You are Away?*

    1. Yes
    2. No
38. How Many People Have Access?
    -- Select One --123
40. First Name*
41. Last Name*
42. Phone Number*
43. Relationship*
    Neighbor, Cleaner, Pet-Sitter, Brother, etc.
45. First Name*
46. Last Name*
47. Phone Number*
48. Relationship*
    Neighbor, Cleaner, Pet-Sitter, Brother, etc.
50. First Name*
51. Last Name*
52. Phone Number*
53. Relationship*
    Neighbor, Cleaner, Pet-Sitter, Brother, etc.
55. Other Person(s) with Access to Premises, If Applicable
    Please list and describe any other person(s) with access to premises, including names, vehicles they drive, their addresses (if known), and their phone numbers. Also indicate the reason(s) for their presence at your residence, i.e. cleaning personnel, pet sitter, etc.
57. Phone Number Where You Can Be Reached
59. Electronic Signature*
    Type your name into this field to indicate your signature.
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit | Go Back