Home Check Form

Fill out the form below, print it and mail to:

PORT WASHINGTON POLICE DEPARTMENT
365 N. Wisconsin St., P.O. Box 365, Port Washington, Wisconsin 53074-0365
Port Washington, WI 53074

The form may also be faxed to the police department at 262-377-9648

Full Name:
Address:
Home Phone:
Reason For Check: Vacation     For Sale     Other
Date Leaving:
Date Returning:
Vehicles In The Garage: Yes     No
Vehicle Descriptions:
Vehicles In The Driveway: Yes     No
Vehicle Descriptions:
Lights On: Yes     No
Constant Lights - Which Rooms:
Timer Lights - Which Rooms:
Pets In Home: Yes     No
Type Of Pets:
Persons Having Access To Home: Phone:
Phone:
Phone:
Emergency Contact Name: Phone: