Request for Security Check: Residence or Business

2. Please complete the online form below to submit your request.

4. Contact Information

6. First Name*

7. Last Name*

9. Date of Request*

10. Departure Date*

11. Return Date*

13. Type of Premises*

    1. Residence
    2. Business
    3. Other

    If "other," please describe the property in the space below.

15. Description of property.

17. Address1*

19. City*

20. State*

21. Zip*

23. Home Phone Number*

24. Cell Phone Number*

26. Email Address*

28. Have you left a key with anyone?*

    1. Yes
    2. No

30. If yes, please provide their information below.

32. Name of Key holder*

33. Email Address of Key Holder

35. Address of Key Holder*

37. City*

38. State*

39. Zip Code*

41. Phone Number of Key Holder*

43. Other Persons who will have access or be working about the premises (neighbors, relatives, workers).

45. Name

46. Email Address

48. Address

50. City

51. State

52. Zip Code

54. Phone Number

56. Name

57. Email Address

59. Address

61. City

62. State

63. Zip Code

65. Phone Number

67. Please add any comments or instructions here.

69. I request the above security check and will notify the Police Department Business Office at 660-747-9133 upon my return.

71. Electronic Signature

    Please type your first and last name.

Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

* indicates a required field