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Ponce Inlet Vacation House Watch

**PLEASE READ** BE ADVISED THIS IS NOT A GUARANTEE THAT YOUR HOUSE WILL BE PUT UNDER A PERMANENT SURVEILLANCE, BUT WILL BE CHECKED IF STAFFING ALLOWS. THIS SERVICE IS ONLY VALID FOR 90 DAYS, EXTENSION OF THIS SERVICE WILL BE ALLOWED FOR AN ADDITIONAL 90 DAYS AND WILL REQUIRE A NEW FORM. ANY REQUEST BEYOND 6 MONTHS, PLEASE CONTACT THE POLICE DEPARTMENT AT 386-236-2160.
First Name*
Last Name*
Street Address*
City
State
Zip Code
Phone Number*
Email Address
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I understand that I can only request a maximum of 90 days for this service. If I require an extension beyond the 90 days, I will submit a new form. *
1. YES
Vacation Dates (90 day maximum) *
Vacation Dates (90 day maximum) Start Date
—
Vacation Dates (90 day maximum) End Date
Do you have any lights on?*
1. Yes
2. No
Location of Lights
Any vehicles in driveway?*
1. Yes
2. No
Vehicle Descriptions (Make, Model, Color) N/A if none*
Will anyone be checking or working on the property?
Please list Name/Business and purpose for being on the property
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Name*
Address*
Phone Number*
Does emergency contact have key?
1. Yes
2. No
Miscellaneous Information
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature*

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