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  Chief of Police - H. Marc Adams
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Vacation Notice Form
Keizer Police Department Vacation Notification Form
Owners Information: (Click here for a PDF Form)
Owner Names:
Address:
Phone:
Date/Time Leaving: Date: Time:
Date/Time Returning Date: Time:
Owner may be contacted at:
 
Special Conditions:
Lights Left On? Yes     No
If lights left on, where?
Timers Used? Yes     No
Keys left with? Name: Phone:
Mail Stopped? Yes     No
Other Deliveries? Yes     No Type:
Persons Authorized on Premises:
Any other conditions you'd like us to know about?
 
Vehicles Left on Premises:
License #: State Registered: Make: Model: Color: Location:
 
Person to contact locally in case of emergencies:
Name:
Address:
Phone:
Relation:
 
Name and Drivers License Number of the Requesting Party:
I agree to hold the Keizer Police Department, City of Keizer, Keizer City Council, Employees, Agents, and Servants harmless from any and all liability upon submission of this Vacation Form.
Name:
Date of Birth:
Drivers License Number:   State:
Email Address: 
 

 

 

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