Residential Patrol Request – City of Breese, Illinois

Complete and submit for a residential patrol request while away for an extended period of time.

Please be advised that any packages located will be brought to the Police Department and resident will receive a text.
Please call the Police Department on your return.
Please secure any exterior doors that no one will be using in case of inclement weather.

Requestor Information

Name:

First Name

Last Name

Date

Address of Property:

City

State/Province

Zip/Postal

Primary Phone Number:

Secondary Phone Number:

Email:

Scheduled Absence

Date Leaving:

Approx. Time Leaving:

Date Returning:

Approx. Time Returning:

What lights did you leave on?

Emergency Contact Name:

Emergency Contact Phone Number:

Is there anything else we need to know?

Acknowledgement

I hereby certify and affirm that the above information is true and correct and that by checking this box constitutes a legal signature confirming my request for residential patrol while I am away.

Electronic Signature:

First Name

Last Name

Captcha